Titusville Rehabilitation & Nursing Center

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

On 11/13/25 at 11:14 AM, the DON stated she was not aware of a 48-hour collection policy for urine samples. A few minutes later the DON returned and said, there was no facility policy on specimen collection that nurses had 48 for the collection. She explained it was the standard of practice for nurses to collect urine specimen as soon as possible. The DON acknowledged the order for resident #5's UA C&S placed at 1:13 PM, yesterday was not collected, and that there were not any progress notes as to why the sample had not been collected over three shifts. The DON was unable to answer why the urine sample was not collected by staff and did not know why some staff thought they had 48 hours to collect the urine.

On 11/13/24 at 1:01 PM, in a telephone interview RN F acknowledged he knew collection of a urine sample was needed for resident #5 because it came up on his tasks in the electronic medical record. He explained

he did not want to wake the resident up in the middle of the night, since she would be able to void in the morning. He said that he passed the message to RN B and the Unit 3 Manager but did not write a progress note about it.

On 11/13/25 at 1:42 PM, the DON said nurses should follow the standard of practice to collect urine specimen as soon as possible.

The facility did not have a policy that specifically addressed specimen collection for diagnostic testing.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Titusville Rehabilitation & Nursing Center

1705 Jess Parrish CT Titusville, FL 32796

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to maintain accurate documentation for medication administration for 1 out of 7 sampled residents, (#7). Findings:Resident #7 was readmitted to

the facility on [DATE REDACTED] with diagnoses which included quadriplegia, neuromuscular dysfunction of the bladder and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED], resident # 7 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. A review of the physician's orders revealed that resident # 7 had orders for Midodrine HCl Oral Tablet 10 milligrams (mg), give one tablet by mouth three times a day for low blood pressure. The order directed nurses to hold the medication if

the systolic blood pressure (the first number) was greater than 120. On 11/13/25 at 12:10 PM, the Medication Administration Record (MAR) indicated the assigned nurse Registered Nurse (RN) B, administered Midodrine 10 mg at 9:00 AM. The MAR had a check mark with the nurse's initial's to indicated

she had administered the medication. The corresponding blood pressure was 125/70 and per the physician's order, the medication should have been held. Further review of the MAR revealed that for November 2025, resident #7 was administered the Midodrine 10 mg outside the physician's ordered parameters a total of 14 times. 12 out of the 14 times by RN B. The MAR revealed in October 2025, resident # 7 received Midodrine 10 mg a total of 28 times documented by six different nurses. RN B documented the medication as given for a total of 17 out of 28 times. On 11/13/25 at 12:17 PM, the Director of Nursing (DON) acknowledged the documentation on the MAR for October and November of 2025 which indicated nurses administered midodrine without following the physician's ordered parameters. The DON could not give a reason why the order was not followed. On 11/13/25 at 12:33 PM, assigned RN B acknowledged the MAR indicated she administered Midodrine 10 mg. The nurse explained she must have checked it off in error because she did not actually give the medication. RN B said she would hold the medication if the resident's blood pressure was greater than 120 and explained she would never give the medication if the systolic blood pressure was greater than 120. She could not say why she did not mark the medication as not given or held on the MAR as she was familiar with the codes for documenting refusals, held, or not available. RN B again acknowledged the MAR contained documentation that she gave the medication when it should have been held and said she could not prove it was not given. She explained she would change today's documentation of the medication and write a progress note to explain the discrepancy. On 11/13/25 at 1:42 PM, the DON could not explain why the nurses documented Midodrine 10 mg was given to resident # 7 when it should have been held. She explained that RN B was immediately educated and confirmed she was just clicking in error. The DON continued to explain that the expectation was to document accurately in the medical record and if it was in error, the nurse should immediately correct the error and/write a follow up note. The facility's policy on Late entry, Addendum, Corrections and Clarification of the Medical Record effective March 2024 revealed, The facility will utilize the following guidelines when documentation problems or mistakes occur and changes or clarifications are necessary.

The procedure for correction in section eight indicated, For electronic record correction, follow the electronic

record process to strike out the error. After striking out the documentation, click follow up to enter corrected note.

Event ID:

Facility ID:

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