Titusville Nursing And Rehab

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety and serve food in a safe and sanitary manner during tray line in the main kitchen.Findings include: Review of facility policy entitled Food Safety Requirements dated 4/23/26, indicated Staff shall adhere to safe hygienic practices to prevent contamination of food from hands or physical objects. Review of facility policy entitled Date Marking for Food Safety dated 4/23/26, indicated The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. And The marking system shall consist of, the day/date of opening, and the day/date the item must be consumed or discarded. Observations during the initial kitchen tour on 6/23/26, between 9:45 a.m. and 10:00 a.m. revealed in the walk-in refrigerator an open container of garlic 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to receive instructions for removal of a urinary catheter (a soft plastic tubing inserted into the bladder to drain urine into a bag) in a timely manner for one of one residents reviewed for catheters (Resident R30).Findings include: Review of facility policy entitled Appropriate Use of Indwelling Catheters dated 4/23/26, indicated Indwelling urinary catheters will be used on a short-term basis., The interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the insertion, continuation, or removal of an indwelling urinary catheter. Review of Resident R30's clinical record revealed an admission date of 4/29/26, with diagnoses that included diabetes (a health condition that is caused by the body's inability to produce enough insulin), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and chronic obstructive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policies, observations and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for two of two medication rooms reviewed (first floor and ground floor medication rooms) and failed to prevent the opportunity for potential unauthorized access of medications on one of three medication carts observed (B wing medication cart). Findings include: Review of a facility policy entitled Labeling of Medications and Biologicals dated 12/11/24, revealed that labels for multi-use vials must include the date the vial was initially opened . and all opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different . date for that opened vial. Review of a facility policy entitled Security of Medication Cart dated 12/11/24, revealed that medication carts must be securely locked at all times when out of the nurse's view. Review of manufacturer's guidelines revealed that an open vial of Tubersol (a solution used for tuberculosis testing upon admission and employment) should be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and clinical records, and resident and staff interviews, it was determined that the facility failed to promote resident choices about aspects of his or her life in the facility that are significant to the resident regarding medication administration for two of 16 residents reviewed (Residents R11 and R51). Findings include: The facility policy entitled Medication Administration-General Guidelines, dated 12/11/24, indicated that medications are administered within 60 minutes of scheduled time. Resident R11's clinical record revealed an admission date of 3/27/23, with diagnoses that included diabetes (condition of improper blood sugar control), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and chronic obstructive pulmonary disease (a progressive lung disease with chronic respiratory symptoms). During an interview with Resident R11 on 6/4/25, at 10:30 a.m. the resident shared that he/she had received medications late on 5/28/25, and had filed a grievance against Licensed Practical Nurse (LPN)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of one residents reviewed for respiratory services (Resident R209). Findings include: Review of facility policy entitled Oxygen Administration dated 12/11/24, revealed Review the physician's order . for oxygen administration. Turn on oxygen. Unless otherwise ordered, start the flow of oxygen at . and adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Review of Resident R209's clinical record revealed an admission date of 5/23/25, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), diabetes (a health condition that caused by the body's inability to produce enough insulin), and acute respiratory failure (a condition where your lungs don't exchange air properly). Review of Resident R209's physician's orders dated 5/23/25, revealed an order for oxygen at 6…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policies and clinical records, observations, and staff interview, it was determined that the facility failed to prevent the potential for cross contamination during a dressing change for one of three residents with pressure ulcers requiring wound care reviewed and also failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) (Resident R109). Findings include: Review of the facility policy entitled, Wound Care, dated 12/11/24, indicated to remove the soiled dressing, remove soiled gloves and then wash hands. Review of the facility policy entitled, Enhanced Barrier Precautions, dated 12/11/24, are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDRO). It also indicated that gloves and gown are to be applied prior to performing the high contact resident care activities, which includes wound care. Review of Resident R109's clinical record revealed an admission date of 10/11/24, with diagnoses that included paraplegia ( loss of feeling in legs and lower…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to notify the physician and begin treatment timely related to a change in a resident's condition, and obtain a physician's order/clarification for the use of an assistive device for two of 17 residents reviewed (Residents R4 and R25). Findings include: Review of facility policy entitled, Change in a Resident's Condition or Status dated 3/28/24, indicated, The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition. Resident R4's admission record revealed an admission date of 4/1/22, with diagnoses that included dementia (condition with symptoms that affect memory and thinking), atrial fibrillation (irregular heart rate), and type II diabetes (condition of insufficient production of insulin). Review of a nursing note dated 7/20/24, at 6:01 p.m. indicated that the physician was faxed information regarding white patches in Resident R4's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment for one resident reviewed for respiratory care (Resident R210). Findings include: Facility policy entitled Departmental (Respiratory Therapy) - Prevention of Infection dated 3/28/24, indicated Infection Control Considerations Related to Oxygen Administration . Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. Resident R210's clinical record revealed an admission date of 7/10/24, with diagnoses that included fracture of right femur (broken bone of the upper leg), hypertension (high blood pressure), and diabetes (a health condition that causes by the body's inability to produce enough insulin). Resident R210's physician orders dated 7/12/24, revealed an order indicating to provide oxygen at 2 liters per minute via nasal cannula (oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery). Observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to provide a clinical rationale and duration for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for one of five residents reviewed for psychotropic medications (Resident R6). Findings include: A facility policy entitled Antipsychotic Medication Use dated 3/28/2024, indicated that PRN orders for psychotropic medications are limited to 14 days and If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. Resident R6's clinical record revealed an admission date of 5/18/17, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and heart failure (a condition where the heart cannot supply the body with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interview, it was determined that the facility failed to ensure that keys to the medication cart and medication room were secured on one of five units reviewed (Unit B). Findings include: Facility policy entitled, Security of Medication Cart dated 3/28/24, indicated, The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. Facility policy entitled, Medication Storage in The Facility dated 3/28/24, indicated, Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Observations on 7/22/24, at 1:30 p.m. in room [ROOM NUMBER] on Unit B revealed the nurse's medication cart and medication room keys were on the resident's bed and were unsecured. At that time, the Director of Nursing (DON) was called to room [ROOM NUMBER] on Unit B. The DON confirmed that the unsecured keys were for the medication cart on Unit B and the medication room. The DON confirmed that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and facility grievances, and staff interviews it was determined that the facility failed to properly and safely administer resident medications on two separate incidents for one of 17 residents (Resident R3) Findings include: Review of facility policy dated 5/25/23, entitled Medication Administration General Guidelines indicated that Medications are to be administered at the time they are prepared. The policy further indicated that The resident is always observed after administration to ensure that the dose was completely ingested. Review of facility policy dated 5/25/23, entitled Documentation of Medication Administration, indicated that a nurse documents all medication administered to each resident on the resident's Medication Administration Record (MAR), it further indicated that the reason why a medication or medications not administered should be documented. Review of a facility grievance form dated 5/29/23, revealed that a family member found a cup of medications at Resident R3's bedside when the family member came to visit on 5/29/23, at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and grievances and staff interviews, it was determined that the facility failed to properly administer resident medications for one of 17 residents (Resident R3) Findings include: Review of facility policy dated 5/25/23, entitled Medication Administration General Guidelines indicated that Medications are to be administered at the time they are prepared. The policy further indicated that The resident is always observed after administration to ensure that the dose was completely ingested. Review of Resident R3's clinical record revealed an admission date of 4/01/22, with diagnoses that included dementia, heart disease, high blood pressure, atrial fibrillation and diabetes. Review of a quarterly Minimum Data Set (MDS-a periodic assessment of resident care needs) assessment for Resident R3, dated 5/19/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) and had severely impaired cognition. Review of a facility grievance form dated 5/29/23, revealed that a family member found a cup of medications at Resident R3's bedside when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.