Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Titusville Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
The facility failed to ensure its QAA/QAPI committee sustained prior improvement measures related to complete and accurate medical records. The same F842 deficiency was cited again after a prior recertification survey, and the repeat citation was attributed to insufficient auditing and oversight. The Administrator stated the QAPI committee met monthly and reviewed clinical metrics, care issues, grievances, and concierge round concerns, but multiple providers still documented on paper, which he felt contributed to records not being complete and accurate.
Pressure ulcer care, wound treatment, and care plan failures: Two residents had deficiencies involving pressure injury management. One resident with severe cognitive impairment, total ADL dependence, diabetes, and a PEG tube developed facility-acquired pressure ulcers while turning/repositioning and skin checks were frequently undocumented, the care plan was not revised after wound changes, and ordered sacral treatment was not documented as performed. Another resident admitted with sepsis, necrotizing fasciitis, paraplegia, and stage 4 pressure injuries had delayed wound vac changes, inconsistent skin assessments, and missing documentation for ordered wound treatments.
Food storage, sanitation, and hot holding practices were deficient. The walk-in refrigerator had food debris and residue, spice bins were dirty, the dry storage room was 76 degrees F with a broken AC unit and expired granola bars, and staff were observed with improper hair/beard covering. During lunch service, potentially hazardous foods on the steam table were below the required 135 degrees F, including sloppy joe, pureed cabbage, and mashed potatoes, and a cook reached into food with ungloved fingers after dropping part of an alcohol wipe into the mashed potatoes.
A resident with a BIMS of 13/15, a hx of TBI, and dependence for all ADLs said she was unhappy, did not feel she belonged, and wanted a transfer to be closer to family. She also preferred to be outside more often, but the facility only allowed residents to leave the building if they smoked. The resident's record lacked documentation of attempts to find alternate placement, and the Administrator could not provide copies of referrals while the SSD said referrals had been sent to nearby facilities.
A resident with bipolar disorder, morbid obesity, and muscle wasting was documented as blind or severely visually impaired, yet her care plan had no interventions for vision loss. The hospital transfer form, MDS, nurse note, and SSD notes all reflected significant vision impairment and a pending cataract surgery issue, but staff confirmed the impairment was not included in the care plan and that the resident signed paperwork without family being called to explain it.
A resident with diabetes, malnutrition, heart disease, and skin cancer had forehead and scalp dressings after outpatient lesion removal, but the facility did not include wound monitoring or care in the comprehensive care plan. The active orders and MARs/TARs did not address the head wounds, and the MDS Coordinator and DON confirmed the IDT care plan had not been revised to reflect the resident’s wound needs.
Failure to assess and treat resident skin impairments. A resident with CVA, flaccid hemiplegia, and bladder dysfunction had orders for Bacitracin to buttock excoriation every shift and was identified as at risk for wounds. The resident reported a worsening right thigh area that had not been assessed, while observation showed bright red drainage on the buttock and a large reddened area on the right upper thigh. Staff documentation was incomplete, an LPN could not locate the ordered Bacitracin, and an UM admitted signing the TAR without providing the treatment.
Failure to Monitor Supplemental Oxygen Therapy: A resident with respiratory failure, COPD, pneumonia, and moderate cognitive impairment was observed receiving continuous O2 by nasal cannula, but the MAR had no physician order for supplemental O2 and no directions to monitor O2 sats. The RN did not recall checking the resident’s O2 status during the shift, and the record showed O2 saturation checks had not been documented for more than six weeks.
A resident with diabetes, malnutrition, heart disease, and skin cancer had forehead and scalp dressings after an outpatient dermatology procedure, but the chart lacked the dermatologist's notes, wound care instructions, and monitoring orders. The resident was observed with undated dressings that staff had not checked, while the RN consultant and DON confirmed the medical record was missing the outpatient records and related documentation.
Surveyors found that the facility failed to maintain a homelike environment on two units, with multiple areas showing chipped paint, broken sheetrock, missing baseboards, holes in walls, and missing tiles. The Maintenance Director reported daily rounds and a reporting system for repairs, but some issues had been awaiting repair for an undetermined period. The Administrator acknowledged the need for repairs to meet resident environment standards.
Two residents did not receive care in accordance with physician orders and professional standards. One resident with hypertension did not have blood pressure monitored or documented as required before administration of antihypertensive medications, and the care plan for cardiovascular issues was delayed. Another resident with symptoms of a UTI experienced a delay in urine specimen collection for ordered diagnostic testing, with no documentation explaining the delay and inconsistent staff communication.
A resident with complex medical needs was documented as receiving Midodrine outside of physician-ordered blood pressure parameters on multiple occasions, with several nurses recording the medication as given despite orders to hold it. The MAR showed repeated documentation errors, and staff interviews confirmed that the medication was not always administered as recorded, nor were proper documentation codes used.
A resident with a Full Code status experienced a delay in CPR initiation due to confusion over contradictory DNR and Full Code orders. The resident was found unresponsive, and the LPN initially followed a hospice chart indicating DNR, leading to a delay in CPR until the code status was confirmed. Discrepancies in the timeline of events were noted, highlighting the facility's failure to promptly verify and act on the resident's code status.
A resident on hospice care was found unresponsive, and due to confusion over their code status, there was a delay in initiating CPR. The LPN initially believed the resident was a DNR based on incorrect hospice information, leading to a delay in CPR and calling 911. The facility's investigation was incomplete, failing to obtain timely staff statements and not reporting the incident to the State Survey Agency.
The facility did not provide a private setting for Resident Council meetings, holding them in an open area near the nurse's station, which led to residents fearing retaliation if they voiced complaints. During a meeting, 20 residents indicated they were afraid to complain about their care, and a review of council minutes showed few concerns were raised, suggesting underreporting due to fear.
The facility did not adequately address Resident Council concerns from June 2023 to June 2024, despite assurances from a new Administrator. The Activity Director, working alone and unaware of unresolved issues, communicated concerns to relevant departments but only received verbal resolutions. The lack of volunteers and the Director's hospitalization also led to a lack of activities, contributing to the Council's grievances.
Facility staff failed to inform residents of their rights, as revealed during a Resident Group meeting and review of Resident Council minutes. Residents and family members reported not receiving information about their rights upon admission or during their stay, and the Resident Council President confirmed that rights were not reviewed in meetings. The Activity Director, responsible for facilitating these meetings, could not provide documentation that resident rights had been reviewed or distributed.
The facility failed to provide a comprehensive activity program for its residents, resulting in a lack of engagement for three residents. One resident was left in bed without activities, another with severe cognitive impairment was not engaged, and a third expressed dissatisfaction with the lack of activities. The Activity Director struggled to manage alone, with no documentation of activities or one-to-one visits.
The facility failed to provide sufficient nursing staff, resulting in delayed medication administration for residents. Nurses were overwhelmed with high resident assignments and shared medication carts, causing significant delays in administering scheduled medications. Despite raising concerns, management did not provide feedback or solutions to address the staffing issues.
The facility failed to administer scheduled medications within the prescribed time for 31 residents due to staffing issues, leading to significant delays. Nurses were on split assignments, sharing medication carts, which caused delays in administering medications for conditions such as high blood pressure, pain, and depression. The facility's policy required medications to be given within one hour of the scheduled time, a guideline that was not followed. The DON acknowledged the issue, and the Medical Director discouraged splitting nurse assignments.
The facility was cited for a repeat deficiency in reporting due to insufficient auditing and oversight by the QAA/QAPI committee. The QAPI Plan required PIP subcommittees to identify improvement areas and report to the QAA Committee, but the facility failed to sustain prior improvements. The Administrator, new to the facility, could not confirm ongoing audits for past citations, acknowledging the system's failure.
The facility failed to update PASARR evaluations for two residents with newly diagnosed mental disorders. One resident, initially admitted with various conditions, was later diagnosed with schizophrenia, anxiety, and depressive disorders, but did not receive an updated PASARR. Another resident, admitted with bipolar disorder, received a new diagnosis of major depressive disorder, yet the PASARR was not updated. The DON and Interim DON acknowledged these oversights.
A resident was admitted with a diagnosis of schizophrenia, but the Level 1 PASARR evaluation completed by the hospital omitted this diagnosis. The interim Administrator and Social Service Director had differing views on responsibility for PASARR accuracy, while the Interim DON acknowledged the oversight and confirmed it was her responsibility to ensure accurate evaluations.
The facility failed to document education, consent, or contraindication for influenza and pneumococcal vaccines for four residents. Despite receiving vaccines, necessary records were missing, contrary to the facility's policy requiring documentation of consent, education, and prior vaccine administration.
A facility failed to maintain accurate medical records and medication administration. A resident's change in condition was not properly documented, with discrepancies in the timing of events and actions taken. Another resident did not receive prescribed eye drops as scheduled, and an LPN prematurely documented the administration. The DON acknowledged these practices were against policy, leading to deficiencies in care.
QAPI Oversight Failed to Sustain Prior Medical Record Improvements
Penalty
Summary
The facility failed to ensure its QAA/QAPI committee conducted performance improvement activities to verify that prior improvement measures were sustained. The report states the facility had previously been cited at F842 for incomplete and inaccurate medical records during the prior recertification survey, and during the current survey it was again found out of compliance with F842. The repeat deficiency was linked to insufficient auditing and oversight to prevent the citation. The Administrator stated the QAPI committee met monthly and reviewed floor rounds, clinical metrics, care issues, grievances, and concerns raised during concierge rounds, and that performance improvement plans were created when issues were identified. He acknowledged the repeat citation and stated that multiple providers still documented on paper, which he felt contributed to medical records not being complete and accurate.
Pressure ulcer care, wound treatment, and care plan failures
Penalty
Summary
The facility failed to provide care and services to maintain the highest practicable physical well-being by not preventing a facility-acquired pressure ulcer, not revising the pressure ulcer care plan after the resident’s wound status changed, and not implementing physician orders for existing pressure ulcers for two residents reviewed for pressure ulcers. One resident was admitted with chronic respiratory failure, a PEG tube, type 2 diabetes, and brain damage from low oxygen, and the admission MDS showed severe cognitive impairment, total dependence for ADLs, and risk for pressure injuries with preventive interventions in place. The care plan identified the resident as at risk for wounds and included turning/repositioning and heel floating, but the TAR showed frequent missing documentation for turning, repositioning, and skin observations across all shifts. For that resident, weekly skin checks later documented new skin impairment, and nursing progress notes identified in-house acquired pressure ulcers including stage 3 wounds to the buttock areas and stage 2 wounds to the sacrum and right buttock. Physician orders were entered for sacral wound treatment, but the TAR showed no documentation that the ordered sacral treatment was performed for several days after the order start date and again on another date. During observations, the resident was repeatedly found lying flat in bed with the head of bed slightly elevated, heels resting on the mattress, and at times exposed with bedding off to the side. Staff interviews confirmed the resident should have been repositioned every two hours, that skin observations were expected each shift, and that the care plan had not been revised to reflect the current wound status. The second resident was admitted with sepsis, necrotizing fasciitis, paraplegia, polyneuropathy, a stage 4 pressure ulcer of the right buttock, and an unstageable pressure ulcer. Hospital paperwork showed the resident had been admitted with a worsening decubitus ulcer that resulted in sepsis, and discharge paperwork included negative pressure wound therapy ordered for the stage 4 right gluteal wound three times weekly. The facility’s TAR did not document the wound vacuum being changed until nine days after admission. Weekly skin checks were inconsistent and listed multiple wound locations without staging or measurements, and the DON acknowledged the assessments did not consistently match the locations, descriptions, and staging of the skin issues. Additional skin evaluations listed wounds as present on admission that had not been documented earlier in the admission assessment, and treatment orders for several wounds had no documentation of being performed on some scheduled dates.
Food Storage, Sanitation, and Hot Holding Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards. During the kitchen tour, the walk-in refrigerator had visible food debris and residue along the baseboards and corners, and two spice bins in the food preparation area had sticky residue and debris in the bottom of the containers. In the dry storage room, the air conditioning unit had its cover off, debris and rust were visible on top of the unit, the room temperature was 76 degrees F, and a bin of granola bars was found past expiration. A dietary aide was also observed with a beard covering that did not fully cover the beard, and the Registered Dietitian was observed with hair net placement that did not cover the front of the hair. During lunch tray line observation, potentially hazardous foods on the steam table were held below the required hot holding temperature of 135 degrees F or greater. The observed temperatures were sloppy joe at 120 degrees F, pureed cabbage at 85 degrees F, and mashed potatoes at 132 degrees F. While checking temperatures, the cook dropped part of an alcohol wipe into the mashed potatoes and reached into the food with ungloved fingers to remove it. Additional observations included rust on wheels of equipment in the food preparation area, and a shelf with three frying pans lying with handles down and debris and food particles next to them. A male dietary aide was also observed handling plates with food without gloves.
Failure to Honor Resident Self-Determination and Transfer Preferences
Penalty
Summary
The facility failed to honor resident rights related to self-determination for one resident who was reviewed for choices. The resident stated she was unhappy at the facility, did not feel like she belonged, and had requested a transfer. She also said she preferred to be outside as much as possible, but the facility only allowed residents to exit the building if they smoked. The resident's quarterly MDS showed a BIMS score of 13/15, indicating she was mostly cognitively intact, and that she was dependent on staff for all ADLs and unable to move from the waist down. The assessment also noted a history of traumatic brain injury, and that she was able to use the internet, hold a conversation, and recall events. The resident had previously sought help from Social Services to move to a skilled nursing facility in a nearby city to be closer to family, and her care plan included a goal to adjust to LTC placement with an intervention for referral to a local contact agency as needed. The Social Services Director stated that several referrals were sent, but the resident was not accepted to facilities in the nearby cities she wanted. The Administrator could not provide copies of referrals, and there were no notes in the medical record showing attempts to find alternate placement per the resident's request. The Social Services Director later stated there were no long-term beds available at one nearby facility and that referrals had been faxed to other nearby facilities, while the DON stated she and the Social Worker were supposed to meet with residents who preferred to move from the facility to assess their needs in a care meeting.
Failure to Care Plan for Blindness and Visual Impairment
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident admitted with bipolar disorder, morbid obesity, and muscle wasting who was also documented as blind or severely visually impaired. The hospital transfer form indicated the resident was blind, the MDS assessment showed severely impaired vision with cognitive intactness and moderate assistance needs, and a nurse progress note documented that the resident was legally blind. Despite these findings, the resident’s care plan contained no interventions related to blindness or impaired vision. The record also showed that Social Services was aware the resident could not see, including a note that cataract surgery needed to be rescheduled and another note that the resident requested help accessing her funds. During interviews, the SSD stated that trouble seeing should be noted in the care plan and that an eye doctor should see the resident, and the DON stated that residents who were blind or visually impaired should have that reflected in their care plan. The Business Office Manager confirmed the resident signed paperwork without the family being called to explain it, and the MDS Coordinator confirmed there was no care plan for the resident’s visual impairment.
Care plan not updated for head wound care
Penalty
Summary
The facility failed to revise the comprehensive care plan to include wound management for a resident with non-pressure related skin conditions. Resident #36, an older female with diagnoses including type 2 diabetes mellitus, adult failure to thrive, malnutrition, heart disease, muscle wasting and atrophy of multiple sites, and left lateral forehead squamous cell carcinoma, was re-admitted to the facility after an acute care hospital stay. The most recent MDS quarterly assessment documented intact cognition and indicated no surgical wounds or wound care during the look-back period. On observation, the resident was found eating breakfast while lying in bed with one small and one large undated bordered adhesive gauze dressing with peeling edges on her forehead and scalp. She stated the dressings had been applied about one week earlier after skin cancer lesions were removed at the dermatologist’s office, and facility nurses had not looked at them since then. The active physician’s orders and MARs/TARs did not include monitoring of the head wounds, and the care plan did not include wound monitoring or care. The MDS Coordinator and DON both confirmed the care plan had not been revised to include the wounds, despite routine IDT and clinical meetings where updates were discussed.
Failure to Assess and Treat Resident Skin Impairments
Penalty
Summary
The facility failed to provide appropriate care consistent with professional standards of practice and failed to provide treatment to promote healing of a resident’s skin condition. The resident was admitted with diagnoses including cerebral infarction, flaccid hemiplegia affecting the dominant right side, and bladder dysfunction. The annual MDS indicated the resident was cognitively intact and at risk for pressure ulcers, with treatments including ointments or medications other than to the feet. Physician orders directed staff to apply Bacitracin to buttock excoriation every shift, and the care plan identified risk for wounds related to impaired mobility, bowel and bladder incontinence, fragile skin, and right-sided hemiplegia. The resident stated she believed there was a wound on her right thigh that no one had looked at and said she was afraid it might be getting worse. She later reported that no nurse had followed up or assessed her right thigh skin. Weekly skin assessments for February documented no new skin impairment on two occasions, and one assessment documented no new skin impairment while also listing redness to the buttock. During observation, the sacral area was covered in thick pink cream paste, the right buttock had bright red drainage, and the right upper thigh had a large bright reddened area. The CNA stated she often applied Desitin to the buttocks but did not put anything on the right thigh because it was new and seemed to be getting bigger. The TAR showed Bacitracin applications documented by the Wing 3 UM and RN A on some shifts, but there were missing signatures for several ordered applications. The assigned LPN could not find the Bacitracin in the treatment cart or stockroom and said she had not yet provided the treatment. The Wing 3 UM stated the resident was not on the wound list and did not have any wounds, said she had not observed the resident’s skin during the week because there were no issues, and later acknowledged she had signed the TAR without providing treatment. The DON acknowledged the sacral and right thigh skin impairments after they were brought to her attention and stated she had not been aware of them previously.
Failure to Monitor Supplemental Oxygen Therapy
Penalty
Summary
The facility failed to monitor supplemental oxygen therapy for a resident with respiratory failure, pneumonia, COPD, sepsis, atrial fibrillation, type 2 diabetes mellitus, and moderate cognitive impairment. The resident was admitted to the facility, then re-admitted from an acute care hospital, and the most recent MDS noted oxygen therapy was administered during the look-back period. On 3/03/26, the resident was observed in bed with a nasal cannula delivering oxygen at 2 LPM, and a joint observation with an RN confirmed continuous supplemental oxygen at 2 LPM. The resident’s active MAR included nebulized respiratory medications, but there were no physician’s orders for supplemental oxygen and no directions to monitor blood oxygen saturations. The care plan addressed oxygen therapy and listed continuous oxygen at 3 LPM, along with nurse monitoring and physician reporting of breathing changes, but the record review found no current oxygen order or monitoring documentation. The RN stated he did not recall checking the resident’s oxygen status during the shift and explained that oxygen saturation should be monitored when supplemental oxygen is being used. Review of the prior 90 days showed oxygen saturations had not been checked for more than six weeks, with the last recorded measurement on 1/27/26. The DON stated nurses were expected to enter orders on re-admission and that the oxygen orders appeared to have been missed.
Incomplete wound documentation and missing outpatient dermatology records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident with non-pressure related skin conditions. The resident was a female with diagnoses including type 2 diabetes mellitus, adult failure to thrive, malnutrition, heart disease, muscle wasting and atrophy of multiple sites, and left lateral forehead squamous cell carcinoma. She had been admitted to the facility and later re-admitted from an acute care hospital. During observation, she was found lying in bed eating breakfast with one small and one large undated bordered gauze dressing with peeling edges on her forehead and scalp, and she stated that skin cancer lesions had been removed at her Dermatologist's office about one week earlier and that facility nurses had not looked at the dressings since then. The resident's active physician orders, MARs/TARs, and care plan did not include monitoring of the head wounds, and the electronic and paper medical records did not contain physician notes or wound care instructions from the outpatient dermatology procedure. A nurse progress note documented that the resident had a head wound dressing after an outpatient appointment, but the record still lacked the most recent dermatology progress notes. The Regional Nurse Consultant stated she could not locate those notes in the medical record, and the DON stated she expected outpatient physician records and related orders to be updated and accessible in the chart, but was unsure what happened to the records.
Failure to Maintain Homelike Environment Due to Unaddressed Maintenance Issues
Penalty
Summary
Surveyors observed multiple maintenance deficiencies on two of three units within the facility, including bubbled and chipped wall paint, broken sheetrock, missing baseboards, holes in walls, unpainted repairs, missing ceramic tiles, and bubbled surfaces on sink bases. These issues were noted in various locations such as the entrance to the 100-unit, outside and inside several resident rooms, and around fixtures like sinks, toilets, and windows. The physical environment in these areas did not meet standards for a safe, clean, comfortable, and homelike setting as required for residents. During interviews, the Maintenance Director stated that daily room rounds were conducted to identify maintenance issues and that staff could report problems verbally or through an electronic system. However, some of the identified deficiencies were already on the project list, but the Maintenance Director could not confirm how long they had been awaiting repair. The Administrator acknowledged the need for repairs to maintain a homelike environment. The facility's policy required timely repair or replacement of damaged structural surfaces, but the observed conditions indicated this was not consistently achieved.
Failure to Monitor Blood Pressure and Timely Collect Urine Specimen
Penalty
Summary
The facility failed to provide appropriate care and treatment according to physician orders and professional standards for two residents. For one male resident with a history of Alzheimer's Disease, stroke, and hypertension, the facility did not consistently monitor and document blood pressure readings as required. Despite being prescribed multiple antihypertensive medications, including one to be administered as needed for elevated systolic blood pressure, nursing staff did not check or record blood pressure at least once daily on 25 occasions over a two-month period. The resident's care plan did not include a cardiovascular/hypertension focus until the day the survey began, and the as-needed medication was never administered, with no documentation to support whether it was needed or not. Interviews with nursing staff, including LPNs, RNs, the Unit Manager, and the DON, revealed a consistent expectation that blood pressure should be checked and documented prior to administering antihypertensive medications. However, the medical record review showed this was not done, and the DON acknowledged the missing entries and the delayed addition of the care plan. Facility guidelines required nurses to obtain and record vital signs prior to medication administration, but this standard was not met for the resident in question. For another resident with diagnoses including muscle wasting, pneumonia, diabetes, and kidney failure, the facility failed to implement a physician's order for a urinalysis with culture and sensitivity in a timely manner. The resident and her son reported symptoms of a urinary tract infection and communicated these to staff, but the urine sample was not collected for over 24 hours after the order was placed. There was no documentation in the medical record explaining the delay, and communication among staff was inconsistent, with some CNAs unaware of the need for specimen collection. The DON confirmed there was no facility policy specifying a 48-hour window for specimen collection and stated that standard practice was to collect samples as soon as possible.
Failure to Accurately Document Medication Administration per Physician Orders
Penalty
Summary
The facility failed to maintain accurate documentation for medication administration for one resident with multiple diagnoses, including quadriplegia and neuromuscular dysfunction of the bladder. The resident had a physician's order for Midodrine 10 mg to be administered three times daily, with instructions to hold the medication if the systolic blood pressure exceeded 120. Review of the Medication Administration Record (MAR) showed that the medication was documented as given on multiple occasions when the resident's systolic blood pressure was above the ordered threshold. Specifically, in November, the medication was recorded as administered 14 times outside the parameters, and in October, 28 times, with several nurses involved in the documentation. Interviews with the assigned RN and the Director of Nursing (DON) confirmed that the MAR contained documentation errors, with the RN acknowledging that she may have checked off the medication as given in error and did not use the appropriate codes for held or not given medications. The DON was unable to provide a reason for the failure to follow the physician's order and acknowledged the expectation for accurate documentation. The facility's policy required corrections to be made in the electronic record, but the errors persisted over multiple months and involved several staff members.
Delay in CPR Due to Code Status Confusion
Penalty
Summary
The facility failed to follow its policy and procedure related to a resident's Full Code status, resulting in a delay in initiating Cardiopulmonary Resuscitation (CPR). The resident, a male with a history of anemia, type II diabetes, and occlusion and stenosis of the carotid artery, was admitted to hospice services with a diagnosis of moderate protein-calorie malnutrition. Despite having a physician's order for full resuscitation, there was confusion regarding the resident's code status, with contradictory orders for Full Resuscitation and Do Not Resuscitate (DNR) entered by an LPN. On the day of the incident, the resident was found unresponsive by a CNA, who reported this to the LPN. The LPN checked the hospice chart, which indicated a DNR order, and called hospice services, which initially confirmed the DNR status. However, hospice later called back to confirm the resident was a Full Code. This confusion led to a delay in initiating CPR, as the LPN waited for confirmation of the resident's code status before starting resuscitation efforts. The facility's documentation and investigation revealed discrepancies in the timeline of events, with conflicting reports from staff, EMS, and hospital records. The Code Blue Worksheet and staff statements indicated different times for when the resident was found unresponsive and when CPR was initiated. The facility's failure to promptly verify and act on the resident's Full Code status placed all residents at risk and resulted in Immediate Jeopardy.
Removal Plan
- CPR was initiated for resident #100 and resident was transferred from the facility with a rhythm via EMS and passed away at the hospital.
- Assistant DON initiated staff education on Code Status Orders and Response Policy and Procedure to include procedure for initiating CPR and documentation of the event. 31 out of 31 licensed nurses were educated. Re-education was initiated for licensed nursing clinical staff to be completed.
- Facility audit of 100 out of 100 residents advance directives was completed, to confirm accuracy of code status present in the front of the medical records and that it matched the physician's orders in the EMR.
- Additional audit of 21 out of 21 residents receiving hospice services conducted to confirm code status of record with hospice matches the facility's record. The hospice chart stored at the facility was combined with the facility's hard chart, removing individual hospice binders.
- The Regional President provided education to the Administrator and Interim DON on their essential core functions and the code of conduct.
- The Risk Management Consultant provided education to the Administrator and DON on the Abuse Prevention Program and conducting thorough investigations.
- A total of 9 Code Blue Drills has been completed covering all shifts in order to ensure staff are knowledgeable and prepared to accurately verify resident code status in an emergency and ensure staff provide CPR in a timely manner.
- Ad Hoc Quality Assurance and Compliance committee reviewed removal plan.
Failure to Timely Report and Investigate Delay in CPR
Penalty
Summary
The facility failed to report potential abuse and/or neglect violations concerning a delay in cardio-pulmonary resuscitation (CPR) for a resident who was a Full Code. The resident, who was on hospice care with a terminal diagnosis, was found unresponsive by a CNA during the night shift. The CNA informed an LPN, who then checked the resident's code status and initially believed the resident was a Do Not Resuscitate (DNR) based on incorrect information from the hospice. This led to a delay in initiating CPR. The LPN called the hospice to verify the resident's code status and was initially told the resident was a DNR. However, the hospice later confirmed that the resident was a Full Code. During this time, the LPN also contacted the physician and the facility's Director of Nursing before starting CPR and calling 911. The EMS report indicated a delay in CPR initiation due to confusion over the resident's code status, with CPR eventually being performed and the resident transported to a hospital. The facility's investigation into the incident was incomplete and inaccurate, as it failed to obtain timely statements from all involved staff and did not submit the required Immediate or 5-Day Report to the State Survey Agency. The Risk Manager acknowledged the discrepancies in the investigation and the need for further information to determine the exact timeline of events. The facility reopened the investigation during the survey due to these inconsistencies and planned to file an immediate report as new information emerged.
Lack of Privacy in Resident Council Meetings Leads to Fear of Retaliation
Penalty
Summary
The facility failed to promote an environment where residents could voice grievances about care and treatment without fear of discrimination or reprisal. During an interview with the Resident Council President, it was revealed that Resident Council meetings were held in a non-private area, specifically the atrium on the back of the 200 hall, which was not conducive to private discussions due to staff presence. The Activity Director confirmed the lack of a private area for these meetings. During a Resident Council Group Meeting held in this open area, 20 residents expressed fear of retaliation if they complained about their care, indicating a significant issue with the facility's handling of resident grievances. A review of Resident Council minutes from March to June 2024 showed few voiced concerns, suggesting a possible underreporting of issues due to fear of retaliation.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to properly and promptly respond to Resident Council concerns and grievances, as evidenced by the Resident Council minutes from June 2023 to June 2024. The minutes revealed that the Council felt their concerns were not addressed or resolved on multiple occasions, including June 2023, August 2023, December 2023, April 2024, May 2024, and June 2024. A new Administrator was introduced in April 2024 and assured the Council that concerns were being addressed, but the Council continued to feel their issues were unresolved in subsequent months. The Activity Director, who worked alone in the department, confirmed that concerns from the April 2024 meeting were not addressed or resolved. The Director explained that Resident Council concerns were communicated to the relevant department, with a two-week follow-up, but resolutions were only received verbally and communicated at the next meeting. The Activity Director was unaware of any unresolved issues, despite the Council's ongoing dissatisfaction. Additionally, the absence of volunteers and the Director's hospitalization led to a lack of activities during that period, further contributing to the Council's grievances.
Failure to Inform Residents of Their Rights
Penalty
Summary
The facility staff failed to review and inform residents of their rights, as evidenced by findings from a Resident Group meeting and review of Resident Council minutes. During a meeting held in an open area near the nurse's station, seven residents and family representatives reported they were unaware of their rights, had not received a copy of their rights upon admission or during their stay, and that these rights were not reviewed during Resident Council meetings. The Resident Council President confirmed that resident rights had not been reviewed in these meetings. A review of the Resident Council minutes from June 2023 to June 2024 showed that while the agenda indicated resident rights were reviewed monthly, there was no documentation or pamphlet provided to confirm this. The Activity Director, responsible for facilitating these meetings since February 2024, could not confirm or provide documentation that resident rights had been reviewed or distributed during the meetings.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the interests and well-being of its residents, as evidenced by the lack of engagement for three sampled residents. Resident #10 was observed spending all his time in bed without participation in any group or individual activities. The Activity Director acknowledged that Resident #10 was often left alone, with minimal interaction, and there was no documentation of any activities provided to him. Similarly, Resident #39, who had severe cognitive impairment, was not engaged in any suitable activities. The Activity Director interacted with Resident #39's roommate but not with him, and there was no record of activities provided to Resident #39. Resident #80 expressed dissatisfaction with the lack of activities, noting that there was nothing to do except watch TV. The Activity Director confirmed that during his leave, no activities were conducted, and he struggled to manage the workload alone. He admitted to not having a list of residents requiring one-to-one visits or documentation of such visits. The facility lacked volunteers, and the Activity Director was the sole staff member responsible for activities, which included attending meetings and writing progress notes. The Activity Director was unable to provide Resident Assessment forms or documentation of group participation and one-to-one visits for Residents #10 and #39.
Insufficient Nursing Staff Leads to Delayed Medication Administration
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of residents, particularly in administering medications on time. Observations and interviews revealed that scheduled 9 AM medications were significantly delayed, with some being administered as late as 11:46 AM and 11:54 AM. This delay was attributed to the insufficient number of nurses available, as one nurse was often assigned to cover multiple wings, leading to a split assignment. The shared use of medication carts further exacerbated the delay, as nurses had to wait for their turn to access the cart. Nurses reported being overwhelmed by the number of residents they were responsible for, with some having up to 47 residents on their assignment. The staffing coordinator and Director of Nursing (DON) acknowledged the staffing issues, noting that the facility was staffed based on census and adjusted for acuity. However, the current staffing levels were insufficient to meet the residents' needs, particularly with the opening of a new wing, which increased the workload without a corresponding increase in staff. The report highlighted that the facility's staffing challenges led to delays in medication administration, with 31 residents receiving their medications outside the prescribed time parameters. Despite concerns being raised by the nursing staff about the unmanageable workload and its impact on resident care, there was no indication of feedback or action from management to address these issues. The DON acknowledged the need for more nurses to provide individualized attention and enhance care, but the current staffing model did not support this need.
Medication Administration Delays Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that scheduled medications were administered within the prescribed time parameters for 31 residents on the 100 Wing during the 7 AM to 3 PM shift. This deficiency was observed through a combination of interviews, observations, and record reviews. Registered Nurse (RN) K and Licensed Practical Nurse (LPN) H were noted to be administering 9 AM medications well past the scheduled time, with some medications being given as late as 1:52 PM. The delay in medication administration was attributed to staffing issues, where nurses were assigned to split assignments between different wings, leading to shared medication carts and further delays. Several residents were directly affected by these delays. For instance, a resident received their 9 AM medications at 11:52 AM, which included medications for high blood pressure, pain, and congestive heart failure. Another resident's medications for anxiety, depression, and high blood pressure were administered at 12:11 PM. The report highlights that the facility's policy required medications to be administered within one hour before or after the scheduled time, a guideline that was not adhered to in these instances. The Director of Nursing (DON) acknowledged the issue, explaining that the split assignment of nurses was due to the facility's census. The DON also noted that there was no documentation indicating that residents, their physicians, or responsible parties were notified of the late medication administration. The Medical Director emphasized the importance of administering medications at specific times and discouraged the practice of splitting nurse assignments between wings.
Repeat Deficiency in Reporting Due to Insufficient Oversight
Penalty
Summary
The facility failed to ensure that its Quality Assessment & Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) committee conducted effective performance improvement activities to sustain prior improvement measures. The facility's QAPI Plan outlined that each Performance Improvement Project (PIP) subcommittee should identify areas for improvement, collect and analyze data, and provide the QAA Committee with a summary report, analysis, and recommendations. However, the facility was cited for a deficiency at F 609 for failing to report during a previous recertification survey and was found to be in noncompliance again for the same issue during the current survey. This repeat deficiency was attributed to insufficient auditing and oversight, as the QAA Committee's action plans/PIPs were typically set for three months and considered complete if the issue was resolved, without ensuring continued audits for previous citations. The Administrator, who had been at the facility for about a month, was unable to confirm whether audits were still being conducted for past citations and acknowledged the system's failure, leading to the repeat violation.
Failure to Update PASARR for Residents with New Mental Disorders
Penalty
Summary
The facility failed to update and refer residents with newly diagnosed mental disorders for Level II Preadmission Screening and Resident Review (PASARR) evaluations. Resident #1, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease and cognitive communication deficit, was later diagnosed with schizophrenia, anxiety, and depressive disorders. Despite these new diagnoses, the facility did not update the resident's Level I PASARR or refer for a Level II PASARR evaluation, as confirmed by the Director of Nursing (DON). Similarly, Resident #72, admitted with bipolar disorder and other conditions, received a new diagnosis of major depressive disorder. However, the facility did not perform a new Level I PASARR or request a Level II evaluation. The Interim DON acknowledged the oversight and confirmed that the resident's PASARR was not updated to reflect the new diagnosis, contrary to the facility's policy requiring PASARR updates following significant changes in a resident's mental condition.
Inaccurate PASARR Evaluation for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure the accuracy of a Level 1 Preadmission Screening and Resident Review (PASARR) evaluation for a resident admitted with a diagnosis of schizophrenia. The resident was admitted from the hospital with this diagnosis, but the Level 1 PASARR completed by the hospital social worker did not include schizophrenia. The interim Administrator indicated that Social Services was responsible for completing PASARRs, while the Social Service Director stated that the Director of Nursing (DON) was responsible for reviewing and ensuring their accuracy. The Interim DON expressed surprise that the resident was admitted with schizophrenia, which necessitated a Level 1 PASARR, and confirmed that it was her responsibility to ensure the accuracy of these evaluations. She acknowledged that the omission of the schizophrenia diagnosis was significant and that another Level 1 PASARR should have been conducted to determine if a Level II PASARR was necessary.
Lack of Documentation for Vaccinations
Penalty
Summary
The facility failed to provide necessary documentation for influenza and pneumococcal vaccinations for four residents out of a sample of five reviewed for immunizations. Specifically, there was no documentation of education, consent, refusal, or medical contraindication for these vaccines. Resident #5, who was admitted with chronic obstructive pulmonary disease, obstructive sleep apnea, dementia, type II diabetes, and heart failure, lacked documentation for the pneumococcal vaccine. Resident #10, with diagnoses including metabolic encephalopathy and dementia, received the influenza vaccine but without documented education or consent. Resident #44, admitted with muscle wasting, metabolic encephalopathy, type II diabetes, and pneumonia, had no documentation for either vaccine. Similarly, Resident #55, with hypertensive emergency and stage 4 chronic kidney disease, received the influenza vaccine without the necessary documentation. The Director of Nursing confirmed the absence of records for education, consent, refusal, or contraindication for the vaccines in question. The facility's policy mandates that all residents be offered the pneumococcal vaccine unless there is documented evidence of prior administration, medical contraindication, refusal, or no order. The influenza vaccine should be offered during the optimal immunization period, typically from October to March. The policy also requires staff to screen new admissions for previous pneumococcal vaccine administration, obtain consent or declination for immunizations, secure a physician's order, review vaccine information with the resident or their representative, and document these actions in the medical record. However, these procedures were not followed for the residents mentioned, leading to the deficiency noted in the report.
Deficiencies in Documentation and Medication Administration
Penalty
Summary
The facility failed to ensure complete and accurate medical records for a resident who experienced a change in condition. A male resident, admitted with diagnoses including anemia, diabetes, and malnutrition, was under hospice care. On a specific date, a Licensed Practical Nurse (LPN) documented that the resident had expired, but there was no prior documentation in the resident's clinical records indicating when the change in condition was identified. Interviews with staff revealed that the resident was found unresponsive earlier than documented, and actions taken were recorded on a CPR log rather than in the clinical record. The Director of Nursing (DON) and other staff acknowledged the lack of documentation in the resident's records. Another deficiency was identified in the administration of medication for a resident with glaucoma. The resident was supposed to receive eye drops twice a day, but on one occasion, the resident and her daughter reported that the medication was not administered as scheduled. The Medication Administration Record (MAR) inaccurately showed that the eye drops were given. An LPN admitted to documenting the administration of the medication before actually administering it, which was against the facility's policy. The DON confirmed that this practice was incorrect and could lead to inaccuracies in medication administration records. These deficiencies highlight issues with documentation and medication administration within the facility. The lack of proper documentation for the resident who expired and the premature recording of medication administration for another resident indicate a failure to adhere to professional standards and facility policies. These actions and inactions contributed to the deficiencies identified during the survey.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 26 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Titusville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vista Manor Healthcare And Rehabilitation Center | 0.1 mi | ★★★★★ | 9 | 4 |
| Royal Oaks Nursing And Rehab Center | 3.9 mi | ★★★★★ | 4 | 0 |
| Solaris Healthcare Merritt Island | 17.9 mi | ★★★★★ | 0 | 0 |
| Space Coast Healthcare And Rehabilitation Center | 18.3 mi | ★★★★★ | 0 | 0 |
| Rockledge Healthcare & Rehabilitation Center | 21.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.