Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vista Manor Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Garbage and refuse were not properly contained, with debris found around the dumpster and both lids left open. The dietary department was responsible for maintaining cleanliness and ensuring the dumpster lids were closed, but staff failed to do so after disposing of trash. Facility policy required coordination to keep the area free of debris and lids in place.
The facility did not consistently ensure food was served at appropriate temperatures or that dietary staff followed proper hand hygiene, including after glove use and when handling clean dishware. A resident with moderate cognitive impairment reported receiving cold food, and staff admitted to pre-filling temperature logs and washing hands without soap due to an empty dispenser. The Dietary Services Manager had not provided in-service training on handwashing, and the facility lacked procedures to maintain food temperature during meal delivery.
A resident with multiple medical conditions and intact cognition repeatedly requested more substantial evening snacks but was routinely provided only crackers, despite expressing his preferences to both nursing and dietary staff. The facility's policy limited snack options to crackers, and the dietary department did not collaborate with the resident to offer alternatives, resulting in the resident's needs and preferences not being accommodated.
A resident with cognitive and physical impairments suffered second and third-degree burns after spilling untested hot coffee served in a Styrofoam cup. The facility failed to verify the coffee's temperature, a common practice among staff using a personal coffee maker. The resident required extensive wound care due to the injury.
A resident sustained a significant skin injury, initially reported as a friction wound, but conflicting accounts suggested it might have been a burn from hot coffee. The facility's DON, who was directly involved, led an inadequate investigation without obtaining necessary statements or interviewing the resident. The Administrator did not report the incident to the SSA or Adult Protective Services, resulting in a deficiency in compliance with the facility's abuse and neglect prohibition policy.
The facility failed to maintain prescribed oxygen flow rates for two residents, leading to potential respiratory complications. Both residents were found with oxygen concentrators set at higher flow rates than ordered by their physicians. Nursing staff and the DON acknowledged the discrepancies and the importance of adhering to the prescribed oxygen flow rates.
The facility failed to ensure staff donned facial hair restraints correctly and allowed dishware to air dry before storing. A Dietary Aide was observed with an improperly worn facial hair restraint, and several large hotel pans were found wet and stacked on top of each other during a kitchen inspection.
A resident with moderate cognitive impairment reported missing personal items to multiple staff members, but no grievance form was filed, leading to a deficiency. Despite awareness of the grievance process, staff failed to document and investigate the missing items, leaving the resident's concerns unaddressed.
A facility failed to ensure a resident prescribed antipsychotic medications had an appropriate diagnosis. The resident, with severe cognitive impairment and no indicators of psychosis, was prescribed Nuplazid for Parkinson's Induced Psychosis, but the medical record incorrectly included a schizophrenia diagnosis. Staff interviews revealed inconsistencies in the documentation and diagnosis process.
A resident with multiple diagnoses, including hemiplegia and contracture of the left hand, was observed without a palm guard or any device to manage her condition. Despite having an order for OT, the care plan did not address her limited range of motion. Staff confirmed the resident had not worn a palm guard for months, and there was no follow-through on therapy recommendations.
Improper Disposal and Containment of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that garbage and refuse were properly disposed of and contained, as observed during an inspection of the garbage disposal area. White and black package wrapping materials and other debris were found littered on the ground around the dumpster, and both dumpster lids were left open. The Dietary Services Manager confirmed that the dietary department was responsible for keeping the area around the dumpster clean but was initially unsure who was responsible for ensuring the lids were closed. Later, the Environmental Services Manager clarified that it was the dietary department's responsibility to keep the area clean and the lids closed, and admitted that he and the Floor Technician had emptied trash into the dumpster earlier that morning but did not close the lids afterward. Review of the facility's policy indicated that the Dietary Services Manager was to coordinate with the Director of Maintenance to maintain the area free of debris and ensure appropriate lids were provided and used.
Deficient Food Temperature Control and Hand Hygiene in Dietary Services
Penalty
Summary
The facility failed to ensure that food was prepared and served at appropriate temperatures and that staff followed proper hand hygiene protocols during food handling and dishware management. During the survey, it was found that temperature logs for previous meals were not completed, and on one occasion, the log was pre-filled before meal preparation and service. Staff admitted to sometimes recording temperatures in advance, and there was no evidence to verify the accuracy of these records. A test tray revealed that food items were served below optimal temperatures, and the facility did not use plate warmers to maintain food temperature during delivery. Both the Dietary Services Manager and Regional Manager acknowledged these issues and the lack of procedures to keep food at palatable temperatures. Additionally, the survey revealed lapses in hand hygiene among dietary staff. The handwashing sink in the kitchen was out of soap, and staff admitted to washing hands with water only or using alternative sinks. One staff member was observed removing gloves and then handling clean dishware without washing or sanitizing hands. The Dietary Services Manager confirmed that no in-service training on handwashing had been provided to dietary staff since her recent employment at the facility. The Assistant Director of Nursing/Infection Control Preventionist emphasized the importance of proper hand hygiene and glove use, confirming that staff were expected to follow these protocols. A resident with multiple medical conditions, including diabetes, bone disorder, and moderate cognitive impairment, reported that food was sometimes served cold, leading her to refuse certain menu items. The facility's own policies required that food be rapidly heated to appropriate temperatures and that staff be knowledgeable in proper dishware handling, but these standards were not consistently met, as evidenced by the survey findings.
Failure to Accommodate Resident Snack Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident by routinely providing only crackers as evening snacks, despite the resident's repeated requests for more substantial alternatives. The resident, a man with diagnoses including anemia, depression, anxiety, chronic pain, gastro-esophageal reflux disease, and stage two chronic kidney disease, had intact cognitive abilities and communicated his dissatisfaction with the limited snack options to both nursing staff and the Dietary Manager. He reported that he consistently received only crackers, with the exception of one occasion when he was given a peanut butter and jelly sandwich, and another when a staff member gave him a personal cookie due to the lack of other options. The resident specifically requested a greater variety of snacks, such as ice cream, popsicles, cookies, sandwiches, or pudding, to address his hunger overnight. The Dietary Manager confirmed that the facility's policy was to provide only saltine crackers, graham crackers, or Goldfish crackers as snacks, with oatmeal creme pies offered only if other options were unavailable. Sandwiches were not routinely stocked for snacks and were only prepared upon specific request from nursing staff. The Dietary Manager acknowledged being aware of the resident's requests for more substantial snacks but had not considered offering alternatives beyond the standard options. The facility's policy indicated that snacks should be provided as identified in individual care plans and that the dietary department should collaborate with residents and staff to identify appropriate snack items, but this was not implemented in practice for this resident.
Failure to Ensure Safe Temperature of Hot Coffee Leads to Resident Burn
Penalty
Summary
The facility failed to ensure the safety of residents by not verifying the temperature of hot coffee before serving it, leading to a burn injury for a resident. This resident, who had cognitive and physical impairments, was given hot coffee in a Styrofoam cup, which he accidentally spilled on his leg, resulting in second and third-degree burns. The resident required ongoing wound care and was at risk for infection and decreased mobility due to the severity of the burns. The incident involved a resident with a history of stroke, left side weakness, and impaired vision, who required assistance with daily activities. Despite these needs, the resident was left unsupervised with a hot beverage, which was not checked for safe temperature. The facility's staff, including a Licensed Practical Nurse (LPN), routinely provided hot coffee to residents early in the morning without verifying the temperature, using a personal coffee maker on the unit. Interviews with staff and residents revealed that the practice of serving untested hot coffee was common, and the facility's policy on serving hot liquids was not followed. The Dietary Manager confirmed that hot beverages should be served in appropriate cups with handles and at a safe temperature, but this protocol was not adhered to, leading to the resident's injury.
Failure to Investigate and Report Resident Injury
Penalty
Summary
The facility failed to implement its abuse and neglect prohibition policy and procedures by not conducting a thorough investigation of an injury of unknown origin for a resident. The incident involved a resident who sustained a significant skin injury on the back of his thigh, which was initially reported as a friction wound by the facility's staff. However, conflicting accounts from the resident, his sister, and various staff members suggested the injury might have been a burn caused by hot coffee. Despite these discrepancies, the facility did not conduct a comprehensive investigation to determine the true cause of the injury or whether it required reporting. The facility's Director of Nursing (DON), who was directly involved in the incident as the assigned nurse, led the investigation, which was a conflict of interest. The investigation lacked thoroughness, as it did not include written statements from key individuals, such as the resident, his sister, or staff members who were present during the incident. The DON and the Administrator failed to interview the resident about his injury, and the investigation was not completed in a timely manner. The Administrator, who was also the facility's Risk Manager, did not report the incident to the State Survey Agency (SSA) or Adult Protective Services, as she believed it did not meet the criteria for reporting based on the information she had at the time. The facility's policies required that all incidents be reported, documented, and investigated thoroughly, with statements obtained from involved parties. However, the investigation into the resident's injury was inadequate, and the facility did not follow its own procedures for handling injuries of unknown origin. The lack of a proper investigation and failure to report the incident as required by policy and regulations resulted in a deficiency in the facility's compliance with its abuse and neglect prohibition policy.
Failure to Maintain Prescribed Oxygen Flow Rates
Penalty
Summary
The facility failed to maintain oxygen flow rates as ordered by the physician for two residents. Resident #100, who has chronic obstructive pulmonary disease (COPD) and other health issues, was observed with an oxygen concentrator set between 4.5 and 5 liters per minute (LPM) instead of the prescribed 2 LPM. The resident did not adjust the oxygen concentrator himself. A registered nurse confirmed the discrepancy and acknowledged that it was the nurse's responsibility to set and monitor the oxygen flow rate as prescribed to prevent respiratory complications, especially for residents with COPD. The Director of Nursing (DON) also confirmed the importance of adhering to the prescribed oxygen flow rate to avoid increasing the resident's carbon dioxide levels and suppressing their respirations. Similarly, Resident #366, who has congestive heart failure and other health issues, was observed with an oxygen concentrator set between 4.5 and 5 LPM instead of the prescribed 3 LPM. The resident did not adjust the oxygen concentrator himself. A registered nurse confirmed the discrepancy and reiterated the nurse's responsibility to set and monitor the oxygen flow rate as prescribed. The DON also emphasized the importance of following the physician's orders to prevent respiratory complications. The facility's oxygen policy requires verification of physician's orders for oxygen administration and adherence to those orders. Both residents were found with oxygen concentrators set at higher flow rates than prescribed, which could lead to serious health complications. The observations and interviews with the nursing staff and DON highlighted a failure to follow the prescribed oxygen flow rates, leading to the identified deficiencies.
Improper Use of Facial Hair Restraints and Wet Nesting of Dishware
Penalty
Summary
The facility failed to ensure staff donned facial hair restraints correctly and allowed dishware to air dry before storing. During an observation of the lunch tray line, a Dietary Aide was seen with his facial hair restraint below his bottom lip, leaving his mustache exposed while handling plates of food. When questioned, the aide admitted he forgot to properly wear the restraint, and neither the cook nor the Area Manager provided an explanation for not correcting the aide. Additionally, during a kitchen inspection, several large hotel pans were found wet and stacked on top of each other, indicating they had not been allowed to air dry before storage. The Food Service Director confirmed that the pans should have been air-dried before being stored.
Failure to Investigate and Resolve Resident Grievance
Penalty
Summary
The facility failed to appropriately record and investigate a grievance to ensure resolution in a timely manner for a resident with end-stage renal disease, cardiac pacemaker, depression, and oxygen dependence. The resident, who had a moderate cognitive impairment, reported missing personal items, including a watch and a black jacket, to multiple staff members. Despite the resident's awareness of the grievance process and previous successful grievance resolutions, no grievance form was filed for the missing items, leading the resident to feel that her concerns were not taken seriously. Interviews with various staff members, including a CNA, laundry staff, an RN, the Unit Manager, the Social Service Director (SSD), the Director of Nursing (DON), and the facility's Administrator, revealed a lack of consistent adherence to the facility's grievance policy. Staff members were aware of the grievance process and the responsibility to file grievances for any resident issues, including missing items. However, they did not follow through with the required documentation and investigation for the resident's missing watch and jacket. The facility's Grievance Program Policy and Procedure outlined the steps for filing and investigating grievances, including the immediate documentation and routing of grievances to the SSD. Despite this policy, the staff's failure to document and investigate the resident's reported missing items resulted in a deficiency. The SSD, who was responsible for overseeing grievances, was not informed of the missing items and therefore did not initiate an investigation, leaving the resident's concerns unaddressed.
Inappropriate Diagnosis for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident prescribed antipsychotic medications had an appropriate diagnosis for its use. The resident, an elderly female with diagnoses including Parkinson's Disease and Paranoid Schizophrenia, was admitted from an acute care hospital. The Minimum Data Set (MDS) Quarterly Assessment indicated severe cognitive impairment with no indicators of psychosis or behavioral symptoms. Despite this, the resident was prescribed Nuplazid, an antipsychotic medication, for diagnoses including Neuroleptic Induced Parkinsonism, Other Hallucinations, and Paranoid Schizophrenia. However, the Preadmission Screening and Resident Review (PASRR) form completed by the hospital documented that the resident did not have a Mental Illness (MI) or Suspected Mental Illness (SMI). The Comprehensive Care Plan also included a focus on psychotropic medication use related to Parkinson's psychosis and paranoid schizophrenia, but the psychiatric progress notes only supported a diagnosis of Parkinson's Induced Psychosis, not schizophrenia. Interviews with facility staff revealed inconsistencies in the documentation and diagnosis process. The Unit Manager and Lead MDS Coordinator both indicated that diagnoses and medication use were regularly reviewed in meetings, and the facility was aware of CMS's focus on the misuse of schizophrenia diagnoses for antipsychotic medications. The Lead MDS Coordinator confirmed that the diagnosis for the resident's antipsychotic medication use was Parkinson's Induced Psychosis, not schizophrenia. The Director of Nursing (DON) admitted to entering a schizophrenia diagnosis after observing increased hallucinations in the resident, but the psychiatric APRN later attributed these hallucinations to Parkinson's Disease with Psychosis. The DON acknowledged that the medical record was incorrect and should have been updated to reflect the accurate diagnosis. The CMS RAI Manual requires physician-documented diagnoses, which were not properly followed in this case.
Failure to Provide Contracture Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident with limited range of motion and contracture care. Resident #25, who had multiple diagnoses including hemiplegia/hemiparesis following cerebral infarction, contracture of the left hand, and vascular dementia, was observed without a palm guard or any other device to manage her contracture. Despite having an order for Occupational Therapy (OT) to evaluate and treat her condition after a hospital readmission, the resident's care plan did not address her limited range of motion or the use of a palm guard. Staff interviews revealed that the resident had previously received OT services, which were discontinued when she started hospice care. The Therapy Director admitted to failing to communicate with the Minimum Data Set (MDS) coordinator to develop a care plan for the resident's contracture management. Additionally, the facility did not have a Restorative Nursing Program (RNP) but instead used a Functional Maintenance Program (FMP), which was supposed to educate direct care staff on preventing worsening contractures and skin breakdown. However, there was no follow-through in ensuring the resident wore the palm guard as recommended. Multiple staff members, including Registered Nurses (RNs) and Certified Nursing Assistants (CNAs), confirmed that they had not seen the resident with a palm guard for several months. They acknowledged the importance of the palm guard in preventing skin breakdown and worsening contractures but noted that no current measures were in place to address the resident's condition. The lack of a comprehensive care plan and proper follow-through on therapy recommendations led to the deficiency in care for Resident #25.
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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) |
|---|---|---|---|---|
| Titusville Rehabilitation & Nursing Center | 0.1 mi | — | 21 | 0 |
| Royal Oaks Nursing And Rehab Center | 3.9 mi | — | 4 | 0 |
| Solaris Healthcare Merritt Island | 17.8 mi | — | 0 | 0 |
| Space Coast Healthcare And Rehabilitation Center | 18.3 mi | — | 0 | 0 |
| Rockledge Healthcare & Rehabilitation Center | 21.1 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.