Space Coast Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Space Coast Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Aug 28, 2026

  Based on interview, and record review, licensed nurses failed to initiate Cardiopulmonary Resuscitation (CPR) to a resident with a Full Code status found unresponsive for 1 of 9 residents reviewed for advance directives, (#1).On [DATE] at approximately 11:20 PM, resident #1 was observed unresponsive in his bed. Registered Nurse (RN) B checked his vitals and notified Licensed Practical Nurse (LPN) C to call 911, Emergency Medical Services (EMS). RN B again checked resident's vitals and found resident #1 to have no pulse and no respirations but did not initiate CPR. […]

• Immediate jeopardy, isolatedF600Aug 2, 2025

  Based on interview, and record review, the facility neglected to ensure necessary care and services were provided by ensuring nurses coordinated with physicians to provide proper provision of care for 1 of 1 resident reviewed for insulin-dependent Diabetes Mellitus with an insulin pump, of a total sample of 5 residents, (#1). The facility failed to recognize the critical need for insulin orders and blood glucose finger sticks upon admission and failed to implement physician ordered finger stick blood glucose monitoring after it was prescribed. These combined failures in care coordination resulted in a lack of proper blood glucose monitoring and treatment for eight days, during which the resident developed Diabetic Ketoacidosis (DKA), a life-threatening condition. […]

• Immediate jeopardy, isolatedF635Aug 2, 2025

  Based on interview, and record review, the facility failed to implement and review physician's admission orders for 1 of 3 residents reviewed for admission orders, of a total sample of 5 residents, (#1). The facility did not verify, implement, or initiate expected treatments and prescribed medications consistent with the resident's medical status and as listed in the hospital discharge summary. The Interdisciplinary Team (IDT) failed to recognize that essential components of the admission orders to maintain a chronic condition, including critical medications were missing or not transcribed into the Electronic Medical Record (EMR). […]

• Immediate jeopardy, isolatedF726Aug 2, 2025

  Based on interview, and record review, the facility failed to ensure nursing staff had the appropriate competencies and skills to obtain and implement critical physician medication admission orders for the care of a resident admitted from the hospital with a diagnosis of Type 1 Diabetes Mellitus for 1 of 3 residents, reviewed for admission orders, of a total sample of 5 residents, (#1).For eight consecutive days following admission, for all three nursing shifts and involving nine different licensed nurses, the facility did not obtain or implement physician orders for routine blood glucose monitoring (finger sticks) or insulin administration. […]

• Immediate jeopardy, isolatedF600Apr 28, 2022

  Based on interview and record review, the facility's nursing staff neglected to provide post-fall care and services including comprehensive physical and neurological assessments, physician notification and frequent monitoring according to accepted standards of practice, for 1 of 2 residents reviewed for falls with major injury, out of a total sample of 9 residents, (#22). The failure to address resident #22's change in condition delayed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was likelihood resident #22 could have fallen again or suffered brain injury, coma, or death from an unidentified head injury. On 3/02/22 at 5:00 PM, resident #22 had an unwitnessed fall. He sustained skin tears and abrasions, and complained of left hip pain. […]