Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Titusville Nursing And Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and diagnoses including Alzheimer's Disease sustained a second degree burn after hot coffee was spilled on the thigh. A CNA obtained the coffee from the employee breakroom in a Styrofoam cup after asking the resident if he/she wanted coffee, and the resident was unable to explain exactly what happened. The record documented redness, blistering, and a broken blister on the left thigh, and the facility failed to ensure the coffee was served from the main kitchen, in an appropriate container, and with proper supervision.
Food was found improperly stored and dated in the kitchen, including an open container of garlic, an unclosed bag of waffles, expired hot dog buns, freezer-burnt English muffins without discard dates, and open pasta packages with missing or expired dates. During tray line, an employee with gloved hands touched multiple kitchen surfaces and the food transport cart, then handled a hamburger bun, hamburger, and cheese for a resident meal without removing gloves or performing hand hygiene.
Failure to timely follow up on urinary catheter removal instructions: A resident with DM, anxiety, and COPD had a urology order for a trial void and catheter removal, with specific monitoring and retention parameters. The record showed the catheter was reinserted per the resident's request, but there was no evidence the facility timely contacted urology for further instructions on whether the catheter should remain or be removed, and an RN confirmed the lack of timely follow-up.
Open vials of Tubersol were found in two medication rooms, one without an open date and another past the discard period, and an LPN left a medication cart unlocked and unattended with medications on top while obtaining milk for a resident, contrary to facility policy.
Two residents with complex medical conditions did not receive their evening medications at their preferred or scheduled times, with doses administered over an hour late on multiple occasions by an LPN. Both residents expressed dissatisfaction with the late administration, and the Infection Control Preventionist confirmed the deviations from policy and resident preference.
A resident with COPD, diabetes, and acute respiratory failure was observed receiving supplemental oxygen at 8.5 L/min via nasal cannula, despite a physician's order for 6 L/min. Facility staff, including the DON, confirmed the oxygen was not set according to the order.
A resident with paraplegia, multiple stage four pressure ulcers, and a urinary catheter did not receive wound care in accordance with infection control protocols. An LPN failed to don a gown and did not perform hand hygiene between removing a soiled dressing and cleansing the wound, despite facility policies requiring these steps for residents with MDROs and indwelling catheters. These lapses were confirmed through observation and staff interviews.
The facility failed to timely notify a physician and begin treatment for a resident's condition change, resulting in an 86-hour delay in administering medication for oral thrush. Additionally, the facility did not obtain a physician's order for an abductor pillow for another resident, leading to inconsistent use and discomfort. Staff interviews confirmed the absence of necessary documentation and care plans.
A resident with a history of femur fracture, hypertension, and diabetes was observed with their nasal cannula improperly stored on the floor, contrary to facility policy requiring it to be kept in a plastic bag when not in use. The DON confirmed the deficiency, highlighting a failure in maintaining proper respiratory care.
A facility failed to document a clinical rationale and duration for the continued use of a PRN psychotropic medication beyond 14 days for a resident with anxiety, COPD, and heart failure. The resident received Vistaril beyond the 14-day limit without the necessary documentation, as confirmed by the DON. This oversight violated the facility's policy on psychotropic medication use.
The facility did not secure medication cart and room keys on Unit B. Facility policies require that medication carts be secured during medication pass and that medication rooms, carts, and supplies be locked or attended by authorized personnel. However, a nurse left the keys unsecured on a resident's bed. The DON confirmed the keys were for the medication cart and room and should be secured at all times.
The facility did not ensure the Infection Preventionist attended two out of four required QAPI Committee meetings between July and December 2023. The facility's policy mandates the Infection Control Representative's presence at these meetings, but attendance records showed no evidence of their participation. This was confirmed by the Nursing Home Administrator.
The facility did not ensure the designated Infection Preventionist (IP) attended Infection Control Committee meetings or worked part-time focusing solely on infection control. The Director of Nursing (DON) served as the IP from November 2023 to May 2024 but could not provide evidence of additional part-time hours dedicated to infection control. A review of meetings from July 2023 to December 2023 showed no IP attendance.
Hot coffee spill caused burn injury to cognitively impaired resident
Penalty
Summary
The facility failed to ensure appropriate safety measures were in place when hot coffee was served to a resident with severe cognitive impairment. Resident R28 had an admission date of 12/7/22 and diagnoses that included Alzheimer's Disease, absence epileptic syndrome, and hypertension. A BIMS score of 7 dated 2/20/26 indicated severe impairment. The facility's Hot Liquids Policy-Food Service stated that all coffee and hot liquids were to be brewed in the main kitchen, recorded at a temperature not to exceed 145 degrees at the point of service, and served in cups appropriate to the resident's ability. On 2/26/26, a CNA called an LPN to the resident's room after the resident spilled hot coffee on the thigh. The nursing note documented redness measuring 9 cm by 8 cm on the left thigh with loose skin from possible blistering, and Tylenol was given for pain. Later that day, the DON documented that the Medical Director assessed the burn area. Additional nursing documentation noted a large red area with scattered blistering on the left thigh, and later that evening one large blister had broken and others were starting to leak. The facility investigation included a CNA statement that after washing and dressing the resident, the CNA asked if the resident wanted coffee, went to get it, and the coffee was spilled on the resident's leg. The investigation also documented that the coffee was obtained from the employee breakroom in a Styrofoam cup, and the resident was unable to say exactly what happened after being interviewed. The report states the facility failed to provide hot liquid from the main kitchen, in an appropriate container, and failed to properly supervise the resident while drinking hot coffee, resulting in a second degree burn to the left thigh.
Food Storage and Tray Line Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored in accordance with food safety standards. During the initial kitchen tour, an open container of garlic was observed in the walk-in refrigerator with a use-by date of 5/9/26. In the upright freezer, there was an open bag of waffles that was not closed, four packages of hot dog buns with a best-by date of 5/26/26, and four packages of English muffins that appeared freezer burnt and had no date indicating when they should be discarded. In the dry storage area, three open packages of pasta were observed, including one with a use-by date of 6/6/26, one with no open or use-by date, and one with no use-by date. The Dietary Manager confirmed that the garlic, hot dog buns, English muffins, and three packages of pasta were beyond their use-by dates and/or lacked dates, and confirmed the waffles were not properly closed to prevent contamination. The facility also failed to serve food in a safe and sanitary manner during tray line in the main kitchen. During tray line, Dietary Employee E2 was observed with gloved hands touching the outside of the refrigerator, countertop, oven door, and food transport cart, then using the same gloves to pick up and place a hamburger bun on a plate, place a hamburger on the bun, and place a slice of cheese on top of the hamburger. Employee E2 did not remove gloves or perform hand hygiene during the process. The Dietary Manager confirmed that Employee E2 touched several items and then touched resident food with the same gloves, and confirmed the employee should have removed gloves, washed hands, and applied new gloves before touching the resident's food.
Failure to Timely Follow Up on Urinary Catheter Removal Instructions
Penalty
Summary
The facility failed to obtain timely instructions from urology regarding removal of a urinary catheter for one resident. The resident was admitted with diagnoses including diabetes, anxiety, and chronic obstructive pulmonary disease. A urology order dated 6/9/26 directed removal of the urinary catheter for a trial to void, with instructions to monitor the resident for six hours after discontinuation and, if no void occurred, to perform straight catheterization and, if greater than 350 mL of urine was retained, to leave the indwelling catheter in place and contact the urology team for next steps. Progress notes showed that on 6/9/26 urology wanted to do a trial void, and later that day the catheter was reinserted per the resident's request. A note on 6/10/26 stated that urology was updated on the urinary catheter and would call back with further instructions, but the record lacked evidence that the facility followed up with urology in a timely manner for further instructions regarding potential catheter removal. During interviews, the RN confirmed there was no evidence of timely follow-up with urology and stated the facility should have reached out to urology in a timely manner.
Failure to Discard Outdated Medications and Secure Medication Cart
Penalty
Summary
The facility failed to properly manage and secure medications in accordance with its own policies and professional standards. In two medication rooms, open vials of Tubersol were found either without an open date or with an open date that exceeded the manufacturer's recommended discard period. Specifically, one vial lacked any indication of when it was opened, making it impossible for staff to determine if it was still safe for use, while another vial was observed to have been open beyond the 30-day discard period. Staff interviews confirmed that these vials should have been discarded and that the facility's policy required proper labeling and timely disposal of multi-use vials. Additionally, a medication cart was observed left unlocked and unattended in a hallway while an LPN went into a pantry to obtain a glass of milk for a resident. Medications were left on top of the cart, and the cart was not within the LPN's line of sight during this time. The LPN confirmed that the cart should have been locked and that medications should not have been left unsecured or out of view, as per facility policy. These actions resulted in the potential for unauthorized access to medications.
Failure to Honor Resident Choice in Medication Administration Timing
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not supporting resident choices regarding the timing of medication administration for two residents. According to facility policy, medications are to be administered within 60 minutes of the scheduled time. However, both residents reported receiving their evening medications significantly later than their preferred and scheduled time of 8:00 p.m. Specifically, one resident received seven medications at 9:25 p.m. on one occasion, and the other resident received five medications at 9:06 p.m. and 9:24 p.m. on two separate occasions. Both residents expressed dissatisfaction with the late administration and indicated a preference for receiving their medications closer to 8:00 p.m. Clinical records confirmed the late administration of medications, and interviews with the residents corroborated these findings. The Infection Control Preventionist also confirmed that the medications were not administered in a timely manner and not in accordance with the residents' stated preferences. The affected residents had medical conditions including diabetes, anxiety, chronic obstructive pulmonary disease, protein-calorie malnutrition, and bipolar disorder, which may require consistent medication timing. The failure to administer medications as scheduled and according to resident preference constituted a violation of resident rights and facility policy.
Failure to Administer Oxygen at Ordered Flow Rate
Penalty
Summary
The facility failed to provide oxygen therapy according to the physician's orders for one resident. Facility policy required staff to review the physician's order and administer oxygen at the prescribed flow rate. The resident, who had diagnoses including chronic obstructive pulmonary disease, diabetes, and acute respiratory failure, had a physician's order for oxygen at 6 liters per minute via nasal cannula. However, multiple observations on the same day showed the resident receiving oxygen at 8.5 liters per minute. The Director of Nursing confirmed that the oxygen was not set according to the physician's order.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols during a dressing change for a resident with multiple stage four pressure ulcers and a urinary catheter. Specifically, a Licensed Practical Nurse (LPN) entered the resident's room without donning a gown, as required by the facility's Enhanced Barrier Precautions (EBP) policy for residents with multi-drug resistant organisms (MDRO) and indwelling catheters. The LPN proceeded to remove the soiled dressing and cleanse the wound without performing hand hygiene between steps, contrary to the facility's wound care policy. The resident involved had a history of paraplegia and multiple stage four pressure ulcers, as well as an MDRO and a urinary catheter, necessitating strict adherence to EBP. The LPN's failure to don appropriate personal protective equipment and perform hand hygiene was confirmed during interviews with both the LPN and the Infection Control Preventionist. These actions were observed and documented during a wound care procedure, and the facility's policies clearly outlined the required infection control measures that were not followed.
Delayed Treatment and Lack of Physician's Order for Assistive Device
Penalty
Summary
The facility failed to notify the physician and begin treatment in a timely manner for a change in a resident's condition, specifically for Resident R4. Resident R4, who was admitted with diagnoses including dementia, atrial fibrillation, and type II diabetes, exhibited white patches in the mouth on 7/20/24. Instead of calling the physician, the nursing staff faxed the information, leading to a delay in receiving a treatment order for Nystatin Mouth/Throat Suspension, which was not administered until 7/24/24, approximately 86 hours after the initial observation. The Director of Nursing confirmed the delay in treatment and acknowledged that the nursing staff should have contacted the physician directly. Additionally, the facility failed to obtain a physician's order or clarification for the use of an assistive device for Resident R25, who had a history of a right hip fracture and repair. The clinical record lacked evidence of a physician's order for an abductor pillow, which was inconsistently used and reportedly caused pain to the resident. Interviews with staff confirmed the absence of a care plan or nurse aide tasks for the pillow's use, and the Therapy Director noted that the pillow was not the appropriate size for the resident. The Corporate Nurse Consultant also confirmed the lack of documentation for the pillow's use.
Improper Respiratory Equipment Care for a Resident
Penalty
Summary
The facility failed to maintain proper care of respiratory equipment for a resident, identified as Resident R210, who was reviewed for respiratory care. The facility's policy on infection control related to oxygen administration requires that the oxygen cannula and tubing used as needed (PRN) be kept in a plastic bag when not in use. However, observations revealed that Resident R210's nasal cannula was not stored properly. Instead, the oxygen tubing was connected to the oxygen concentrator, and the prongs that go into the nostrils were found laying on the floor on multiple occasions. Resident R210's clinical record indicated an admission with diagnoses including a fracture of the right femur, hypertension, and diabetes. Physician orders dated 7/12/24 specified providing oxygen at 2 liters per minute via nasal cannula. Despite these orders, the nasal cannula was observed on the floor on 7/22/24 and 7/23/24, with a piece of tape wrapped around the tubing dated 7/17/24. The Director of Nursing confirmed during an interview that the nasal cannula should not be on the floor and should be placed in a bag when not in use, indicating a failure to adhere to the facility's infection control policy.
Failure to Document Clinical Rationale for Extended PRN Psychotropic Use
Penalty
Summary
The facility failed to adhere to its policy regarding the administration of PRN psychotropic medications, specifically for a resident identified as R6. The policy mandates that PRN orders for psychotropic medications are limited to 14 days unless a clinical rationale and duration for continued use are documented by the prescriber. However, the facility did not provide a clinical rationale or specify a duration for the continued use of Vistaril, an anti-anxiety medication, beyond the initial 14-day period. This oversight was identified during a review of Resident R6's Medication Administration Record (MAR), which showed that the PRN Vistaril order was revised multiple times without including the necessary documentation for extending its use. Resident R6, who was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety, and heart failure, received PRN Vistaril on several occasions beyond the 14-day limit set by the original order. The Director of Nursing confirmed that the PRN Vistaril order lacked the required stop date and clinical rationale for its continued use beyond 14 days. This deficiency was identified during a survey, highlighting a failure in the facility's adherence to its own resident care policies and nursing services regulations.
Unsecured Medication Keys on Unit B
Penalty
Summary
The facility failed to ensure the security of medication cart and medication room keys on Unit B. According to the facility's policies, the medication cart should be secured during medication pass, and medication rooms, carts, and supplies should be locked or attended by authorized personnel. However, during an observation, it was found that the nurse's medication cart and medication room keys were left unsecured on a resident's bed. The Director of Nursing confirmed that these keys were for the medication cart and room on Unit B and acknowledged that they should be secured at all times and not left in a resident's room.
Infection Preventionist Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure the required attendance of the Infection Preventionist at the Quality Assurance and Performance Improvement (QAPI) Committee meetings for two out of four quarterly meetings between July 2023 and December 2023. According to the facility's policy, the Infection Control Representative is mandated to serve on the QAPI Committee, which is scheduled to meet monthly. However, a review of the QAPI Committee Attendance Records for the specified period showed no evidence of the Infection Preventionist's attendance at the required meetings. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of the Infection Preventionist from the meetings as required by the facility's policy.
Infection Preventionist Attendance and Role Deficiency
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) attended the Infection Control Committee meetings and worked at the facility focusing solely on infection control at least part-time, as required. The Director of Nursing (DON) was assigned the role of the IP from November 2023 through May 2024. However, the DON, who works full-time, could not provide evidence of completing additional part-time hours dedicated to infection control beyond their full-time duties. Furthermore, a review of the Infection Control Committee meetings from July 2023 through December 2023 showed no attendance or sign-in by an IP. During an interview, the Nursing Home Administrator confirmed the absence of evidence showing an IP's attendance at the meetings during the specified period. The DON also confirmed the lack of proof for completing additional part-time hours focused on infection control.
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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.
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Nursing homes near Titusville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oil City Nursing And Rehab | 12.2 mi | ★★★★★ | 1 | 0 |
| Oakwood Heights Village | 14.7 mi | ★★★★★ | 19 | 0 |
| Caring Place, The | 17.7 mi | ★★★★★ | 12 | 0 |
| Upmc Northwest Transitional Care Unit | 17.7 mi | ★★★★★ | 0 | 0 |
| Sugar Creek Care Center | 18.4 mi | ★★★★★ | 8 | 0 |
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