Titusville Rehabilitation & Nursing Center

In the surveyor’s words

From the most serious findings on record at Titusville Rehabilitation & Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jun 7, 2024

  Based on interview, and record review, the facility failed to follow policy and procedure related to Full Code status leading to a delay in initiating Cardiopulmonary Resuscitation (CPR) for 1 of 5 residents reviewed for Advance Directives of a total sample of 68 residents, (#100). Resident #100 a-[AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included anemia, type II diabetes, occlusion and stenosis of the carotid artery. The resident was admitted to Hospice services on [DATE] with diagnosis of moderate protein-calorie malnutrition. The resident's physician's order dated [DATE] noted full resuscitation. Progress note dated [DATE] at 6:30 AM, documented by Licensed Practical Nurse (LPN) A read, Patient has expired Hospice notified MD (Medical Doctor) notified. […]

• No harm, potential for more than minimal, widespreadF867Mar 5, 2026

  Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the policy and procedure, QAPI Facility Plan dated 10/19/25, revealed the QAPI committee monitored progress to ensure that interventions or actions were implemented and were effective in making and sustaining improvements.The facility had a deficiency cited at F842 for complete and accurate medical records during the previous recertification survey conducted 6/03/24 through 6/07/24. During this survey, the facility was found to again be in noncompliance with F842. […]

• No harm, potential for more than minimal, patternF725Jun 4, 2026

  Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff was available on 1 of 3 units to meet residents' needs related to the timely administration of scheduled medications, (Unit 2).Findings: Cross Reference F755 1. During a medication pass observation with Licensed Practical Nurse (LPN) A on 6/03/26 at 10:05 AM, eight residents listed on the electronic Medication Administration Record (MAR) appeared in red, indicating their scheduled morning medications had not yet been administered. When asked why the residents' names appeared in red, LPN A stated the morning medications were past due. She explained nurses were expected to administer 9:00 AM medications between 8:00 AM and 10:00 AM. […]

• No harm, potential for more than minimal, patternF755Jun 4, 2026

  Based on observation, interview, and record review, the facility failed to provide pharmaceutical services in accordance with professional standards of practice by: failing to appropriately dispose of medications during medication administration for 1 of 2 residents reviewed during medication pass observations (#4); failing to accurately account for and document controlled substance administration and maintain security of medications for 1 of 4 residents reviewed for narcotic administration, (#11); and failing to administer medications according to physician orders and the facility's established medication administration schedule for 10 residents on 1 of 3 units reviewed, out of 19 sampled residents, (#1, #3, #5, #13, #14, #15, #16, #17, #18, and #19). […]

• No harm, potential for more than minimal, patternF842Jun 4, 2026

  Based on interview, and record review, the facility failed to maintain a complete and accurate medical record for one of one residents sampled for wound treatments, of a total sample of 19 residents, (#3).Findings:Medical record review revealed resident #3 was admitted to the facility on [DATE] with diagnoses that included colostomy, pressure ulcers to his left heel, right and left buttock and left hip.A colostomy is a surgical opening in the abdomen to allow stool to exit the body when it cannot pass through the rectum. […]