Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Vista Manor Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Inform and Document Diabetes Care Change: A resident with type II DM and multiple chronic conditions was re-admitted after hospital treatment that included insulin, but the admitting LPN obtained a high BG and no DM meds or BG monitoring orders were continued. The attending MD decided not to continue insulin, believing the resident was on hospice, although she was not, and the resident’s surrogate decision makers were not informed or documented as agreeing to the change. Clinical staff reviewed the admission paperwork and care plan, but the diabetic treatment plan was not clearly communicated, leaving the resident without DM monitoring or treatment until she later developed severe illness and was transferred to the hospital.
Failure to Provide Diabetic Monitoring and Treatment: An IDT failed to recognize that a resident with type II DM, CKD, and recurrent UTIs needed a diabetic treatment plan after re-admission. Although an abnormal BG was documented, staff did not notify the MD, no diabetic orders were entered, and BG monitoring stopped for weeks. Staff later gave conflicting explanations about hospice status and family wishes, but there was no documentation that the resident or representative declined diabetic care. The resident was ultimately found with severe hypoxia and a BG reading too high for the device, then transferred by 911 with sepsis and HHS requiring ICU care.
A resident with type II DM was re-admitted with hospital records showing uncontrolled hyperglycemia and insulin orders, but the facility did not carry over diabetic treatment or BG monitoring. An LPN recorded an abnormal BG of 273 mg/dl on admission but did not verify orders or report it, and the IDT did not address the missing diabetic plan. Weeks later, the resident was found in distress with a BG reading of “high,” was sent by 911 to the hospital, and was admitted to the ICU with sepsis and HHS.
QAPI failed to identify and address a breakdown in diabetes care for a resident with type II DM after the hospital stopped oral meds and started insulin, but the admitting nurse did not enter the order and the resident went without diabetic monitoring or treatment. The resident was later found with severe hypoxia and an unreadable BG, was sent to the hospital, and was admitted to the ICU with BG 945 mg/dl, sepsis, and HHS. The DON, NHA, and MD confirmed there was no formal PIP or QAPI review until the issue was raised during survey.
A resident with fall risk, weakness, and significant ADL assistance needs slid out of bed during peri-care when a CNA rolled her away from the caregiver instead of toward the caregiver. Nursing staff assessed the resident after the fall, but she later developed worsening pain and a change in condition, and the hospital x-ray showed an acute comminuted impacted fracture of the humeral head and surgical neck. Interviews confirmed the resident could not roll herself and required extensive assistance for bed mobility and transfers.
A CNA failed to preserve a resident’s dignity during meal assistance by standing over her while feeding her. The resident had dysphagia, hemiplegia/hemiparesis, severe cognitive impairment, and was dependent on staff for eating. The CNA acknowledged she should have been seated beside the resident, and the DON stated staff were expected to sit at eye level when assisting with meals so dignity would be respected.
Failure to coordinate PASRR findings with the resident assessment process for one resident. A resident had PTSD documented in the record and on the MDS, but the updated PASRR was not aligned with the assessment documentation until later matrix review. The Social Services Director, MDS Coordinator, and DON stated the diagnosis was not recognized or acted upon through the IDT process when it was initially identified.
Failure to include PTSD in the care plan: A resident admitted from an acute care hospital had PTSD documented in a psych eval, BH progress notes, and MDS assessments, but the diagnosis was not reflected in the care plan until later. The SS Director, MDS Coordinator, and DON all acknowledged the omission and could not explain why the diagnosis was not incorporated into the interdisciplinary care planning process.
A resident with respiratory failure, COPD, CHF, and dependence on supplemental O2 was observed receiving oxygen by nasal cannula, but the medical record had no physician order for O2. Staff interviews confirmed the resident was on oxygen without an order, even though the care plan addressed O2 use and the facility policy required verification of a provider order before oxygen administration.
Garbage and refuse were not properly contained, with debris found around the dumpster and both lids left open. The dietary department was responsible for maintaining cleanliness and ensuring the dumpster lids were closed, but staff failed to do so after disposing of trash. Facility policy required coordination to keep the area free of debris and lids in place.
The facility did not consistently ensure food was served at appropriate temperatures or that dietary staff followed proper hand hygiene, including after glove use and when handling clean dishware. A resident with moderate cognitive impairment reported receiving cold food, and staff admitted to pre-filling temperature logs and washing hands without soap due to an empty dispenser. The Dietary Services Manager had not provided in-service training on handwashing, and the facility lacked procedures to maintain food temperature during meal delivery.
A resident with multiple medical conditions and intact cognition repeatedly requested more substantial evening snacks but was routinely provided only crackers, despite expressing his preferences to both nursing and dietary staff. The facility's policy limited snack options to crackers, and the dietary department did not collaborate with the resident to offer alternatives, resulting in the resident's needs and preferences not being accommodated.
A resident with cognitive and physical impairments suffered second and third-degree burns after spilling untested hot coffee served in a Styrofoam cup. The facility failed to verify the coffee's temperature, a common practice among staff using a personal coffee maker. The resident required extensive wound care due to the injury.
A resident sustained a significant skin injury, initially reported as a friction wound, but conflicting accounts suggested it might have been a burn from hot coffee. The facility's DON, who was directly involved, led an inadequate investigation without obtaining necessary statements or interviewing the resident. The Administrator did not report the incident to the SSA or Adult Protective Services, resulting in a deficiency in compliance with the facility's abuse and neglect prohibition policy.
The facility failed to maintain prescribed oxygen flow rates for two residents, leading to potential respiratory complications. Both residents were found with oxygen concentrators set at higher flow rates than ordered by their physicians. Nursing staff and the DON acknowledged the discrepancies and the importance of adhering to the prescribed oxygen flow rates.
The facility failed to ensure staff donned facial hair restraints correctly and allowed dishware to air dry before storing. A Dietary Aide was observed with an improperly worn facial hair restraint, and several large hotel pans were found wet and stacked on top of each other during a kitchen inspection.
A resident with moderate cognitive impairment reported missing personal items to multiple staff members, but no grievance form was filed, leading to a deficiency. Despite awareness of the grievance process, staff failed to document and investigate the missing items, leaving the resident's concerns unaddressed.
A facility failed to ensure a resident prescribed antipsychotic medications had an appropriate diagnosis. The resident, with severe cognitive impairment and no indicators of psychosis, was prescribed Nuplazid for Parkinson's Induced Psychosis, but the medical record incorrectly included a schizophrenia diagnosis. Staff interviews revealed inconsistencies in the documentation and diagnosis process.
A resident with multiple diagnoses, including hemiplegia and contracture of the left hand, was observed without a palm guard or any device to manage her condition. Despite having an order for OT, the care plan did not address her limited range of motion. Staff confirmed the resident had not worn a palm guard for months, and there was no follow-through on therapy recommendations.
Failure to Inform and Document Change in Diabetes Treatment Plan
Penalty
Summary
The facility failed to coordinate, communicate, and document a change in the diabetic treatment plan for a chronically ill resident who required a surrogate for decision making. The resident had a history of type II diabetes mellitus with hyperglycemia, chronic kidney disease, heart failure, obesity, prior myocardial infarction, and bladder dysfunction. She was re-admitted to the facility from the hospital with diagnoses that included UTI and urinary retention, and the hospital records showed she had been treated with insulin lispro and had a blood glucose of 239 mg/dl on the day before discharge. On admission to the facility, the LPN obtained a blood glucose fingerstick of 273 mg/dl and reviewed the hospital discharge paperwork, which did not include diabetic medications. The LPN called the attending physician to reconcile medications, but no orders for diabetic medications or blood glucose monitoring were given, and the abnormal blood glucose result was not reported to the resident or her representative. The admitting nurse also did not ask how the resident managed her diabetes. The baseline care plan was started with diabetic interventions such as fingerstick monitoring and diabetic medications, but there were no physician orders supporting that plan. During the clinical review process, the unit managers, DON, MDS Director, and attending physician reviewed the admission documents and medication orders, but the resident’s diabetic treatment plan was not addressed. The attending physician stated he knew the resident had previously been treated for diabetes and decided not to continue insulin, believing she was a hospice resident and that hyperglycemia was preferable to hypoglycemia, although he later acknowledged she was not on hospice during this admission. He also stated he had spoken with the resident’s representatives about the diabetic plan, but no documentation of that conversation was available. The resident’s husband and son stated they were not informed that she was not receiving diabetic medications or daily blood glucose monitoring, and they did not agree to a change in her diabetes care. The care conference record documented that medications, care, treatments, and therapies were reviewed, but it did not show that the representatives were informed of the diabetic treatment plan.
Failure to Provide Diabetic Monitoring and Treatment
Penalty
Summary
The facility’s Interdisciplinary Team failed to protect a type II diabetic resident from neglect by not identifying the need for a diabetic treatment plan after her re-admission. The resident had a history of uncontrolled diabetes, chronic kidney disease, recurrent urinary tract infections, obesity, atrial fibrillation, heart disease, and a prior myocardial infarction. After re-admission from the hospital, her blood glucose was documented as elevated, but there were no orders for diabetic treatment or ongoing glucose monitoring from that point until she was transferred to the hospital 48 days later. The resident had previously been managed during a short respite stay with oral diabetic medications, daily blood glucose checks, and lab monitoring, with fingerstick results averaging between 120 mg/dl and 240 mg/dl. After the later re-admission, the facility recorded an abnormal blood glucose of 273 mg/dl, but the result was not immediately reported to the attending physician and no new diabetic orders were entered. Her blood glucose was then not monitored again until the day she was transferred to the hospital. Progress notes later reflected provider concern about persistent hyperglycemia and poor glycemic control, but the record did not show that the resident received diabetic monitoring or treatment during that interval. Staff interviews showed the abnormal blood glucose was not escalated during the admission process or discussed in the morning clinical meeting. The LPN who reviewed the admission paperwork stated she did not see diabetic orders and did not notify the physician because she expected the team to discuss the issue later. The UM confirmed the team did not discuss the resident’s diabetes or abnormal blood glucose. The attending physician and APRN gave differing explanations for why diabetic care was not ordered, including hospice-related concerns and family preferences, but there was no documentation that the resident or representative declined diabetic care. On the day of transfer, the resident was found with severe hypoxia, cold clammy skin, pallor, and a blood glucose reading that exceeded the device’s measurement capability, and she was sent by 911 to the hospital with sepsis and HHS, where her blood glucose was 945 mg/dl and she required ICU admission.
Failure to Coordinate Diabetic Care and Monitoring
Penalty
Summary
The facility failed to coordinate and communicate effectively among the interdisciplinary team to ensure a diabetic resident received continuity of care in accordance with the resident’s care plan, orders, and preferences. The resident had type II diabetes, chronic kidney disease, obesity, atrial fibrillation, heart disease, a history of myocardial infarction, a stage 3 sacral pressure ulcer, and neuromuscular bladder dysfunction. After re-admission from the hospital, the resident’s hospital records listed uncontrolled diabetes with hyperglycemia and included insulin Lispro with meals and at bedtime along with finger stick blood glucose monitoring, but the facility did not establish or continue diabetic treatment orders after admission. On admission, an LPN obtained a blood glucose finger stick that read 273 mg/dl, documented the result, but did not check whether there were diabetic medication orders and did not report the abnormal result to the attending physician. The LPN stated she was busy with other admissions and expected the clinical team to discuss the abnormal blood glucose at the morning meeting. The unit manager later stated the abnormal result should have been reported to the attending physician. The resident was transferred to another unit, and the clinical team did not discuss diabetic management again until the resident was sent to the hospital weeks later. The record review showed no orders for diabetic treatment or blood glucose monitoring from re-admission until the resident’s emergency transfer to the hospital. Although the resident had a CCD diet order, there were no documented diabetic medication or monitoring orders, and the dietician’s assessment did not reflect a diabetic plan based on the abnormal blood glucose result or the hospital documents. The attending physician later documented that the resident’s diabetes was unstable and that blood glucose, A1c, renal function, and symptoms of hypo/hyperglycemia should be monitored, but he stated those were not orders. On the day of the emergency transfer, an LPN found the resident with severe respiratory distress and a blood glucose reading of “high,” and EMS identified diabetic hyperglycemia as the primary impression. Hospital records showed the resident was admitted to the ICU with sepsis and HHS and had a blood glucose level of 945 mg/dl.
QAPI Failed to Address Breakdown in Diabetes Care Coordination
Penalty
Summary
The facility failed to ensure its QAPI program identified and addressed a systemic breakdown in coordination, communication, and continuity of care related to diabetes management for a resident with type II diabetes. After the resident was re-admitted from the hospital on 1/28/26, the hospital had discontinued oral diabetic medications and started insulin, but the admitting nurse did not enter the order, and the resident went without diabetic care until she was transferred to the hospital on 3/17/26. When the resident was found on 3/17/26, she had severe hypoxia, cold clammy skin, pallor, and a blood glucose finger stick reading that was too high for the device to measure. She was sent to the hospital by 911 and admitted to the ICU, where she was found to have a blood glucose level of 945 mg/dl, sepsis, and HHS. The resident had a diagnosis of type II diabetes and had not been monitored or treated since her re-admission. The DON acknowledged that the incident was not taken to QAPI and that no PIP was created at the time of the event. The facility stated it conducted audits of diabetic residents after the resident returned, but documentation of those audits and any QAPI review was not available. The DON, NHA, and Medical Director confirmed there was no formal performance improvement project or QAPI review after the resident’s hospitalization, and the NHA stated the facility did not believe the incident needed investigation because the resident’s elevated blood glucose was not considered preventable and she had been transferred due to hypoxia.
Failure to Prevent an Avoidable Fall With Fracture During Bed Care
Penalty
Summary
The facility failed to prevent an avoidable fall with fracture for one resident who had documented needs for assistance with bed mobility and transfers. The resident was an older female with intact cognition on the MDS, a history of weakness, cardiac conditions, nerve pain, spinal stenosis, a urinary catheter, and bowel incontinence. Her care plan identified fall risk and ADL assistance needs, and rehabilitation staff reported she required maximum assistance for bed mobility and transfers, including a mechanical lift with two staff for transfers. On the evening of the fall, a CNA was providing peri-care while the resident was lying on her left side. The CNA instructed the resident to roll over to the right side, and the resident rolled toward the edge of the bed and slid off the right side. The CNA stated she tried to prevent the fall by keeping a hand on the resident’s hip and upper leg, but the resident’s legs went off the bed followed by her right hip and right shoulder. Nursing staff responded, assessed the resident, and documented a skin tear to the right shin and complaints of pain. The resident was returned to bed with a mechanical lift and two staff. After the fall, the resident continued to report pain, and later developed a change in condition that led to transfer to the hospital. The facility’s initial x-rays of the right shoulder and forearm were read as showing no fracture, but the hospital x-ray obtained after transfer showed an acute comminuted impacted fracture of the right humeral head and surgical neck. Interviews with the CNA, nurses, DON, ADON, family members, and other CNAs confirmed the resident could not move well, could not roll herself, and that staff expected residents to be rolled toward the caregiver during bed care. The DON and NHA also described conflicting x-ray interpretations after the resident’s hospital transfer.
Failure to Preserve Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote a dignified existence for Resident #9 when a CNA stood over the resident while assisting her with eating. Resident #9 was admitted with diagnoses including dysphagia, hemiplegia and hemiparesis, need for assistance with personal care, and major depressive disorder. Her quarterly MDS assessment dated 3/26/26 showed a BIMS score of 06/15, indicating severe cognitive impairment, and documented impairments to both upper and lower extremities with dependence on staff for eating. During meal observation on 4/06/26 at 12:34 PM, Resident #9 was in bed with the head of the bed elevated and her meal tray on an overbed table positioned on the left side of the bed. CNA B was observed standing on the resident’s left side while scooping food with a spoon and assisting her with the meal. CNA B later acknowledged she had stood over the resident and stated she knew she was not supposed to do that and should have been seated beside her. The DON stated she was aware a staff member had been observed standing over Resident #9 during feeding and said her expectation was for staff to sit at eye level when assisting with meals so each resident’s dignity would be respected.
Failure to Coordinate PASRR Findings With Resident Assessment
Penalty
Summary
The facility failed to coordinate Level I PASRR findings with the resident assessment process for one resident reviewed for PASRR. Resident #4’s initial PASRR dated 11/24 did not identify PTSD, but an updated PASRR completed on 4/07/2026 identified PTSD and required the resident’s assessment documentation to be updated. The resident’s annual MDS assessment included PTSD as a diagnosis, and the record also contained a psychiatric evaluation dated 2/20/25 that identified PTSD as part of the resident’s mental health diagnoses. Despite the PTSD diagnosis being present in the record, it was not recognized or acted upon until the facility reviewed its matrix in April 2026. The Social Services Director stated the diagnosis had been in the record since July when the MDS Coordinator added it to the diagnosis section of the MDS, but it was not discussed or identified by the IDT except by the MDS Coordinator. The MDS Coordinator stated diagnoses were reviewed in morning interdisciplinary meetings and updated in the medical record as needed, but did not explain why the PTSD diagnosis was not identified or addressed. The DON stated the PTSD diagnosis documented on the PASRR was not reflected in the resident’s assessment documentation and was not incorporated into the interdisciplinary process when initially identified, and acknowledged the issue was an oversight.
Failure to Include PTSD in Care Plan
Penalty
Summary
The facility failed to develop and/or revise a comprehensive, person-centered care plan to address a diagnosis of Post-Traumatic Stress Disorder (PTSD) for one resident reviewed. The resident was admitted from an acute care hospital, and a psychiatric evaluation dated 2/20/25 identified PTSD as part of the resident’s mental health diagnoses. Behavioral health progress notes dated 3/28/25, 7/14/25, 7/31/25, 8/21/25, 9/17/25, 9/23/25, 10/1/25, 10/14/25, and 10/28/25 documented PTSD, and comprehensive and quarterly MDS assessments identified PTSD in Section I as an active diagnosis. Review of the resident’s care plans showed no care plan for trauma until 4/08/26. On 4/8/26, the Social Services Director stated the PTSD diagnosis was present in the record but was not addressed in care planning prior to identification of the diagnosis on 4/06/26, and acknowledged the omission was not identified until then. The MDS Coordinator stated diagnoses were entered into the MDS and reviewed in interdisciplinary meetings but could not explain why PTSD was not incorporated into the care plan. The DON stated the PTSD diagnosis was not incorporated into the interdisciplinary care planning process and was not reflected in the resident’s care plan prior to April 2026, and acknowledged this was an oversight.
Missing Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician’s order before administering oxygen therapy to one resident reviewed for O2 use. Resident #89 was admitted with diagnoses including respiratory failure with hypoxia, chronic obstructive pulmonary disease, congestive heart failure, and dependence on supplemental oxygen. The resident was observed in bed with a nasal cannula delivering oxygen at 2.5 liters per minute, and he stated he had just returned from the hospital after treatment for shortness of breath, swollen legs, and pneumonia. The Minimum Data Set indicated he was cognitively intact, required moderate assistance from staff, and used continuous oxygen. Record review showed there was no physician’s order for oxygen in the medical record, even though the care plan identified that the resident used O2 for pneumonia and respiratory failure and directed staff to monitor for difficulty breathing. Staff interviews confirmed the absence of an order: the unit manager could not find one in the computer and confirmed the resident was on oxygen without an order, while the DON and Administrator stated that oxygen use should be reflected in an order and documented in the order set. The facility’s Oxygen Administration Policy stated staff must verify the provider order prior to administering oxygen and that oxygen should be delivered at the flow rate prescribed by a physician.
Improper Disposal and Containment of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that garbage and refuse were properly disposed of and contained, as observed during an inspection of the garbage disposal area. White and black package wrapping materials and other debris were found littered on the ground around the dumpster, and both dumpster lids were left open. The Dietary Services Manager confirmed that the dietary department was responsible for keeping the area around the dumpster clean but was initially unsure who was responsible for ensuring the lids were closed. Later, the Environmental Services Manager clarified that it was the dietary department's responsibility to keep the area clean and the lids closed, and admitted that he and the Floor Technician had emptied trash into the dumpster earlier that morning but did not close the lids afterward. Review of the facility's policy indicated that the Dietary Services Manager was to coordinate with the Director of Maintenance to maintain the area free of debris and ensure appropriate lids were provided and used.
Deficient Food Temperature Control and Hand Hygiene in Dietary Services
Penalty
Summary
The facility failed to ensure that food was prepared and served at appropriate temperatures and that staff followed proper hand hygiene protocols during food handling and dishware management. During the survey, it was found that temperature logs for previous meals were not completed, and on one occasion, the log was pre-filled before meal preparation and service. Staff admitted to sometimes recording temperatures in advance, and there was no evidence to verify the accuracy of these records. A test tray revealed that food items were served below optimal temperatures, and the facility did not use plate warmers to maintain food temperature during delivery. Both the Dietary Services Manager and Regional Manager acknowledged these issues and the lack of procedures to keep food at palatable temperatures. Additionally, the survey revealed lapses in hand hygiene among dietary staff. The handwashing sink in the kitchen was out of soap, and staff admitted to washing hands with water only or using alternative sinks. One staff member was observed removing gloves and then handling clean dishware without washing or sanitizing hands. The Dietary Services Manager confirmed that no in-service training on handwashing had been provided to dietary staff since her recent employment at the facility. The Assistant Director of Nursing/Infection Control Preventionist emphasized the importance of proper hand hygiene and glove use, confirming that staff were expected to follow these protocols. A resident with multiple medical conditions, including diabetes, bone disorder, and moderate cognitive impairment, reported that food was sometimes served cold, leading her to refuse certain menu items. The facility's own policies required that food be rapidly heated to appropriate temperatures and that staff be knowledgeable in proper dishware handling, but these standards were not consistently met, as evidenced by the survey findings.
Failure to Accommodate Resident Snack Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident by routinely providing only crackers as evening snacks, despite the resident's repeated requests for more substantial alternatives. The resident, a man with diagnoses including anemia, depression, anxiety, chronic pain, gastro-esophageal reflux disease, and stage two chronic kidney disease, had intact cognitive abilities and communicated his dissatisfaction with the limited snack options to both nursing staff and the Dietary Manager. He reported that he consistently received only crackers, with the exception of one occasion when he was given a peanut butter and jelly sandwich, and another when a staff member gave him a personal cookie due to the lack of other options. The resident specifically requested a greater variety of snacks, such as ice cream, popsicles, cookies, sandwiches, or pudding, to address his hunger overnight. The Dietary Manager confirmed that the facility's policy was to provide only saltine crackers, graham crackers, or Goldfish crackers as snacks, with oatmeal creme pies offered only if other options were unavailable. Sandwiches were not routinely stocked for snacks and were only prepared upon specific request from nursing staff. The Dietary Manager acknowledged being aware of the resident's requests for more substantial snacks but had not considered offering alternatives beyond the standard options. The facility's policy indicated that snacks should be provided as identified in individual care plans and that the dietary department should collaborate with residents and staff to identify appropriate snack items, but this was not implemented in practice for this resident.
Failure to Ensure Safe Temperature of Hot Coffee Leads to Resident Burn
Penalty
Summary
The facility failed to ensure the safety of residents by not verifying the temperature of hot coffee before serving it, leading to a burn injury for a resident. This resident, who had cognitive and physical impairments, was given hot coffee in a Styrofoam cup, which he accidentally spilled on his leg, resulting in second and third-degree burns. The resident required ongoing wound care and was at risk for infection and decreased mobility due to the severity of the burns. The incident involved a resident with a history of stroke, left side weakness, and impaired vision, who required assistance with daily activities. Despite these needs, the resident was left unsupervised with a hot beverage, which was not checked for safe temperature. The facility's staff, including a Licensed Practical Nurse (LPN), routinely provided hot coffee to residents early in the morning without verifying the temperature, using a personal coffee maker on the unit. Interviews with staff and residents revealed that the practice of serving untested hot coffee was common, and the facility's policy on serving hot liquids was not followed. The Dietary Manager confirmed that hot beverages should be served in appropriate cups with handles and at a safe temperature, but this protocol was not adhered to, leading to the resident's injury.
Failure to Investigate and Report Resident Injury
Penalty
Summary
The facility failed to implement its abuse and neglect prohibition policy and procedures by not conducting a thorough investigation of an injury of unknown origin for a resident. The incident involved a resident who sustained a significant skin injury on the back of his thigh, which was initially reported as a friction wound by the facility's staff. However, conflicting accounts from the resident, his sister, and various staff members suggested the injury might have been a burn caused by hot coffee. Despite these discrepancies, the facility did not conduct a comprehensive investigation to determine the true cause of the injury or whether it required reporting. The facility's Director of Nursing (DON), who was directly involved in the incident as the assigned nurse, led the investigation, which was a conflict of interest. The investigation lacked thoroughness, as it did not include written statements from key individuals, such as the resident, his sister, or staff members who were present during the incident. The DON and the Administrator failed to interview the resident about his injury, and the investigation was not completed in a timely manner. The Administrator, who was also the facility's Risk Manager, did not report the incident to the State Survey Agency (SSA) or Adult Protective Services, as she believed it did not meet the criteria for reporting based on the information she had at the time. The facility's policies required that all incidents be reported, documented, and investigated thoroughly, with statements obtained from involved parties. However, the investigation into the resident's injury was inadequate, and the facility did not follow its own procedures for handling injuries of unknown origin. The lack of a proper investigation and failure to report the incident as required by policy and regulations resulted in a deficiency in the facility's compliance with its abuse and neglect prohibition policy.
Failure to Maintain Prescribed Oxygen Flow Rates
Penalty
Summary
The facility failed to maintain oxygen flow rates as ordered by the physician for two residents. Resident #100, who has chronic obstructive pulmonary disease (COPD) and other health issues, was observed with an oxygen concentrator set between 4.5 and 5 liters per minute (LPM) instead of the prescribed 2 LPM. The resident did not adjust the oxygen concentrator himself. A registered nurse confirmed the discrepancy and acknowledged that it was the nurse's responsibility to set and monitor the oxygen flow rate as prescribed to prevent respiratory complications, especially for residents with COPD. The Director of Nursing (DON) also confirmed the importance of adhering to the prescribed oxygen flow rate to avoid increasing the resident's carbon dioxide levels and suppressing their respirations. Similarly, Resident #366, who has congestive heart failure and other health issues, was observed with an oxygen concentrator set between 4.5 and 5 LPM instead of the prescribed 3 LPM. The resident did not adjust the oxygen concentrator himself. A registered nurse confirmed the discrepancy and reiterated the nurse's responsibility to set and monitor the oxygen flow rate as prescribed. The DON also emphasized the importance of following the physician's orders to prevent respiratory complications. The facility's oxygen policy requires verification of physician's orders for oxygen administration and adherence to those orders. Both residents were found with oxygen concentrators set at higher flow rates than prescribed, which could lead to serious health complications. The observations and interviews with the nursing staff and DON highlighted a failure to follow the prescribed oxygen flow rates, leading to the identified deficiencies.
Improper Use of Facial Hair Restraints and Wet Nesting of Dishware
Penalty
Summary
The facility failed to ensure staff donned facial hair restraints correctly and allowed dishware to air dry before storing. During an observation of the lunch tray line, a Dietary Aide was seen with his facial hair restraint below his bottom lip, leaving his mustache exposed while handling plates of food. When questioned, the aide admitted he forgot to properly wear the restraint, and neither the cook nor the Area Manager provided an explanation for not correcting the aide. Additionally, during a kitchen inspection, several large hotel pans were found wet and stacked on top of each other, indicating they had not been allowed to air dry before storage. The Food Service Director confirmed that the pans should have been air-dried before being stored.
Failure to Investigate and Resolve Resident Grievance
Penalty
Summary
The facility failed to appropriately record and investigate a grievance to ensure resolution in a timely manner for a resident with end-stage renal disease, cardiac pacemaker, depression, and oxygen dependence. The resident, who had a moderate cognitive impairment, reported missing personal items, including a watch and a black jacket, to multiple staff members. Despite the resident's awareness of the grievance process and previous successful grievance resolutions, no grievance form was filed for the missing items, leading the resident to feel that her concerns were not taken seriously. Interviews with various staff members, including a CNA, laundry staff, an RN, the Unit Manager, the Social Service Director (SSD), the Director of Nursing (DON), and the facility's Administrator, revealed a lack of consistent adherence to the facility's grievance policy. Staff members were aware of the grievance process and the responsibility to file grievances for any resident issues, including missing items. However, they did not follow through with the required documentation and investigation for the resident's missing watch and jacket. The facility's Grievance Program Policy and Procedure outlined the steps for filing and investigating grievances, including the immediate documentation and routing of grievances to the SSD. Despite this policy, the staff's failure to document and investigate the resident's reported missing items resulted in a deficiency. The SSD, who was responsible for overseeing grievances, was not informed of the missing items and therefore did not initiate an investigation, leaving the resident's concerns unaddressed.
Inappropriate Diagnosis for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident prescribed antipsychotic medications had an appropriate diagnosis for its use. The resident, an elderly female with diagnoses including Parkinson's Disease and Paranoid Schizophrenia, was admitted from an acute care hospital. The Minimum Data Set (MDS) Quarterly Assessment indicated severe cognitive impairment with no indicators of psychosis or behavioral symptoms. Despite this, the resident was prescribed Nuplazid, an antipsychotic medication, for diagnoses including Neuroleptic Induced Parkinsonism, Other Hallucinations, and Paranoid Schizophrenia. However, the Preadmission Screening and Resident Review (PASRR) form completed by the hospital documented that the resident did not have a Mental Illness (MI) or Suspected Mental Illness (SMI). The Comprehensive Care Plan also included a focus on psychotropic medication use related to Parkinson's psychosis and paranoid schizophrenia, but the psychiatric progress notes only supported a diagnosis of Parkinson's Induced Psychosis, not schizophrenia. Interviews with facility staff revealed inconsistencies in the documentation and diagnosis process. The Unit Manager and Lead MDS Coordinator both indicated that diagnoses and medication use were regularly reviewed in meetings, and the facility was aware of CMS's focus on the misuse of schizophrenia diagnoses for antipsychotic medications. The Lead MDS Coordinator confirmed that the diagnosis for the resident's antipsychotic medication use was Parkinson's Induced Psychosis, not schizophrenia. The Director of Nursing (DON) admitted to entering a schizophrenia diagnosis after observing increased hallucinations in the resident, but the psychiatric APRN later attributed these hallucinations to Parkinson's Disease with Psychosis. The DON acknowledged that the medical record was incorrect and should have been updated to reflect the accurate diagnosis. The CMS RAI Manual requires physician-documented diagnoses, which were not properly followed in this case.
Failure to Provide Contracture Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident with limited range of motion and contracture care. Resident #25, who had multiple diagnoses including hemiplegia/hemiparesis following cerebral infarction, contracture of the left hand, and vascular dementia, was observed without a palm guard or any other device to manage her contracture. Despite having an order for Occupational Therapy (OT) to evaluate and treat her condition after a hospital readmission, the resident's care plan did not address her limited range of motion or the use of a palm guard. Staff interviews revealed that the resident had previously received OT services, which were discontinued when she started hospice care. The Therapy Director admitted to failing to communicate with the Minimum Data Set (MDS) coordinator to develop a care plan for the resident's contracture management. Additionally, the facility did not have a Restorative Nursing Program (RNP) but instead used a Functional Maintenance Program (FMP), which was supposed to educate direct care staff on preventing worsening contractures and skin breakdown. However, there was no follow-through in ensuring the resident wore the palm guard as recommended. Multiple staff members, including Registered Nurses (RNs) and Certified Nursing Assistants (CNAs), confirmed that they had not seen the resident with a palm guard for several months. They acknowledged the importance of the palm guard in preventing skin breakdown and worsening contractures but noted that no current measures were in place to address the resident's condition. The lack of a comprehensive care plan and proper follow-through on therapy recommendations led to the deficiency in care for Resident #25.
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We read the 38 citations issued within 25 miles in the last 12 months — including the 4 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) |
|---|---|---|---|---|
| Titusville Rehabilitation & Nursing Center | 0.1 mi | ★★★★★ | 21 | 0 |
| Royal Oaks Nursing And Rehab Center | 3.9 mi | ★★★★★ | 4 | 0 |
| Solaris Healthcare Merritt Island | 17.8 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.