Cycle 1
Health 2024-06-07 · Fire 2024-06-07
14 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Titusville, FL
Titusville Rehabilitation & Nursing Center
2-star overall rating with 2-star inspections with $17,369 in total fines with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1705 Jess Parrish Ct, Titusville, FL
(321) 269-5720
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
157
Certified beds
Average residents
93
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Florida Institute For Long-Term Care
Operator or chain grouping
Approved since
1984-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
18 facilities
Chain averages 2 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.61
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.39
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.96
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
91%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,771
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.76
Composite VBP score used to determine payment impact.
Payment multiplier
0.9867
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.41
Baseline 21.00% · Performance 20.32% · Measure score 2.41 · Achievement 2.41 · Improvement 1.21
Healthcare-associated infections
4.90
Baseline 5.94% · Performance 6.37% · Measure score 4.90 · Achievement 4.90 · Improvement 0
Total nurse turnover
3.82
Baseline 67.00% · Performance 48.78% · Measure score 3.82 · Achievement 3.65 · Improvement 3.82
Adjusted total nurse staffing
1.57
Baseline 3.69 hours · Performance 3.52 hours · Measure score 1.57 · Achievement 1.57 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.21% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 106 · Observed rate 14.15% · Lower 95% interval 7.83% |
| Discharge to community | 58.77% |
50.57%
8.2 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 57.41% · Lower 95% interval 48.73% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 58 · Denominator 58 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 58 |
| Discharge self-care score | 44.74% |
53.69%
8.9 pts worse
|
Numerator 17 · Denominator 38 |
| Discharge mobility score | 23.68% |
50.94%
27.3 pts worse
|
Numerator 9 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 1.72% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 58 · Adjusted rate 1.79% |
| Healthcare-associated infections requiring hospitalization | 6.37% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 5.66% · Lower 95% interval 3.98% |
| Staff COVID-19 vaccination coverage | 71.29% |
8.2%
63.1 pts better
|
Numerator 72 · Denominator 101 |
| Staff flu vaccination coverage | 12% |
42%
30 pts worse
|
Numerator 15 · Denominator 125 |
| Discharge function score | 36.84% |
56.45%
19.6 pts worse
|
Numerator 14 · Denominator 38 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
1.2
1 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
97.8%
1.6 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
2.6%
1 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.1% · Q3 4.4% · Q4 5.5% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
3.7%
3.4 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
5.9%
1 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.1% · Q3 2.6% · Q4 7.2% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.4% |
15.7%
6.7 pts worse
|
19.6%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 20.0% · Q3 21.2% · Q4 22.9% · 4Q avg 22.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.9% |
9.8%
3.9 pts better
|
16.7%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 3.7% · Q3 3.4% · Q4 6.5% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.0% |
11.7%
4.7 pts better
|
16.3%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 9.5% · Q4 13.6% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.2% |
9.8%
3.6 pts better
|
14.9%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.6% · Q3 8.0% · Q4 9.0% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.3% |
12.5%
4.2 pts better
|
19.8%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 2.3% · Q3 6.6% · Q4 17.5% · 4Q avg 8.3% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
5.1%
0.1 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 5.8% · Q3 2.5% · Q4 4.4% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
94.3%
3.5 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 98.1% · Q3 98.9% · Q4 98.8% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.6% |
9.3%
3.7 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 6.2% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.5%
1.3 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.0% · Q3 4.1% · Q4 4.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.0% |
94.7%
4.3 pts better
|
79.7%
19.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.5% |
26.2%
5.3 pts worse
|
23.9%
7.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.5% · Observed 31.2% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-16 · Fire 2022-06-16
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-01-06 · Fire 2021-01-06
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-06-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-07
D · Potential for more than minimal harm
2024-06-07
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-07-07
E · Potential for more than minimal harm
2021-01-06
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2021-01-31
D · Potential for more than minimal harm
2021-01-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-01-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-30
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2026-01-30
D · Potential for more than minimal harm
2025-11-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-13
D · Potential for more than minimal harm
2025-11-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-13
J · Immediate jeopardy
2024-06-07
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-07-14
E · Potential for more than minimal harm
2024-06-07
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-07-14
E · Potential for more than minimal harm
2024-06-07
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-07-14
E · Potential for more than minimal harm
2024-06-07
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2024-07-14
E · Potential for more than minimal harm
2024-06-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-14
E · Potential for more than minimal harm
2024-06-07
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-07-14
E · Potential for more than minimal harm
2024-06-07
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-07-14
E · Potential for more than minimal harm
2024-06-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-14
E · Potential for more than minimal harm
2024-06-07
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-07-14
D · Potential for more than minimal harm
2024-06-07
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-07-14
D · Potential for more than minimal harm
2024-06-07
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-07-14
D · Potential for more than minimal harm
2024-06-07
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-07-14
D · Potential for more than minimal harm
2024-06-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-14
E · Potential for more than minimal harm
2022-06-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-08
D · Potential for more than minimal harm
2022-06-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-07-08
D · Potential for more than minimal harm
2021-01-06
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2021-01-31
D · Potential for more than minimal harm
2021-01-06
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2021-01-31
D · Potential for more than minimal harm
2021-01-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2021-01-31
D · Potential for more than minimal harm
2021-01-06
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-01-31
D · Potential for more than minimal harm
2021-01-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-01-31
Penalties and ownership
What sits behind the stars
$17,369
2024-06-07
Fine
Fine · fine $17,369
Fine
Ownership
Florida Institute For Long Term Care LLC
5% Or Greater Indirect Ownership Interest · Organization
Cole, Kathleen
Operational/Managerial Control · Individual
Consulting Support Services, LLC
Operational/Managerial Control · Organization
Eleus Health Management LLC
Operational/Managerial Control · Organization
Facility Support Company, LLC
Operational/Managerial Control · Organization
Hamil, Corey
Operational/Managerial Control · Individual
Jaffe, Howard
Corporate Officer · Individual
Kane Financial Services, LLC
Operational/Managerial Control · Organization
Katz-Hall, Kathy
Corporate Officer · Individual
Mullarkey, James
Corporate Officer · Individual
Omega Healthcare Investors, Inc
5% Or Greater Mortgage Interest · Organization
Richmond, Penny
Corporate Officer · Individual
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#3
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