Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, nurses failed to follow physician's orders and failed to monitor condition
changes in a timely manner for 1 of 3 residents reviewed for Change of Condition, of a total sample of 4
residents, (#4).
Residents Affected - Few
Findings:
Review of the medical record revealed resident #4, an [AGE] year old male was admitted to the facility on
[DATE], re-hospitalized on [DATE], and re-admitted from an acute care hospital on [DATE]. The resident's
diagnoses included hemiplegia and hemiparesis following cerebral infarction (stroke), aphasia (language
communication dysfunction), dysphagia (difficulty swallowing), end stage kidney disease, seizures,
encephalopathy (brain dysfunction), hypertensive (high blood pressure) urgency, dialysis dependence,
anemia, primary hypertension, and coronary (heart) artery disease (CAD).
The Minimum Data Set 5-Day assessment with an Assessment Reference Date of 11/06/24 showed during
the look back periods, resident #4 scored 13 out of 15 on the Brief Interview for Mental Status exam that
indicated he was cognitively intact. The assessment noted there were no behaviors or rejections of
evaluation or care, received scheduled pain medications, received one injection, high-risk anti-platelet, and
anti-convulsant medications, and hemodialysis while a resident.
The Comprehensive Care Plan included focuses, interventions, and goals for altered cardiovascular status
related to CAD, hypertension, anemia with interventions for nurses to monitor for changes and
complications, and hemodialysis therapy with interventions for nurses to observe and monitor for
complications and side effects including elevated blood pressure.
The December 2024 Order Recap report included physicians medication orders for: Carvedilol 25
Milligrams (MG) once daily every Monday, Wednesday, Friday, and Sunday morning, and once in the
evening on Tuesday, Thursday, and Saturday for high blood pressure, Clonidine 0.3 MG three times daily
every Monday, Wednesday, Friday, and Sunday, and once in the evening every Tuesday, Thursday, and
Saturday for high blood pressure, Hydralazine 100 MG three times daily every Monday, Wednesday, Friday,
and Sunday, and once in the evening every Tuesday, Thursday, and Saturday for high blood pressure,
Isosorbide Mononitrate 30 MG once daily every Monday, Wednesday, Friday, and Sunday morning, and
once in the evening on Tuesday, Thursday, and Saturday for angina with a hold for blood pressure
parameters, Metoprolol 100 MG twice daily every Monday, Wednesday, Friday, and Sunday, and once in the
evening every Tuesday, Thursday, and Saturday for high blood pressure, and Nifedipine 60 MG twice daily
every Monday, Wednesday, Friday, and Sunday and once in the evening every Tuesday, Thursday, and
Saturday for high blood pressure.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
105904
Printed: 05/28/2026
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
105904
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Atlantic Shores Nursing and Rehab Center
4251 Stack Blvd
Melbourne, FL 32901
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the Nurse Progress Note completed by Licensed Practical Nurse (LPN) B on 12/12/24 at 12:48
AM, revealed the nurse received an additional as needed physician's medication order of Clonidine 0.2 MG
to treat resident #4's elevated blood pressure reading of 232/91 mmHg (millimeters of mercury).
The Order Audit Report noted on 12/11/24 at 11:03 PM, LPN B entered physician's medication orders for
Clonidine 0.2 MG every six hours as needed for systolic blood pressure greater than 170 or diastolic blood
pressure greater than 90 mmHg.
The eINTERACT Change In Condition Evaluation completed by LPN A and the South Unit Manager on
12/12/24 documented the dialysis center contacted the facility to report that resident #4 required
emergency transport to the hospital when he arrived at the dialysis center for treatment in the afternoon on
12/12/24.
On 1/28/25 at 10:55 AM, in a telephone interview, LPN B recalled that on 12/12/24 during the 11:00 PM to
7:00 AM shift, resident #4 had an elevated blood pressure which she reported to the nurse practitioner by
phone. LPN B said she obtained medication orders and administered the medication. She explained she
recorded subsequent blood pressures during the night in the medical record.
On 1/27/25 at 2:15 PM, LPN A recalled that on 12/12/24, she took resident #4's blood pressure before he
went to dialysis and administered medication for an elevated reading. She said the same afternoon, a little
while after he left for dialysis, the facility was notified by the dialysis center they had initiated 911 for
emergency transport to the hospital. LPN A said LPN B had not mentioned during oncoming report on
12/12/24 that resident #4's blood pressure was high and the provider had been notified.
Review of the Weights and Vitals Summary report noted resident #4's blood pressure was recorded as
167/91 on 12/11/24 at 10:47 PM, by LPN B but was not documented again until 12/12/24 at 12:41 PM by
LPN A, approximately 12 hours later.
The December 2024 Medication Administration Record (MAR) noted the only as needed dose of
anti-hypertensive blood pressure medication was the Clonidine 0.2 MG which was administered by LPN A
on 12/12/24 at 12:41 PM.
On 1/27/25 at 2:25 PM, the South Unit Manager recalled at lunchtime on 12/12/24, she noticed resident #4
was lying in bed which was different than his normal routine of being out of bed in his wheelchair. She said
she thought he may not be feeling great and noticed hadn't eaten any of his lunch. She explained nurses
took the resident's blood pressure which was elevated, so an as needed dose of medication was
administered before he went to dialysis treatment at approximately 1:00 PM. She said she remembered
seeing a note earlier that morning from the night shift nurse about the resident's blood pressure that
required a provider notification and additional medication orders.
Review of the pharmacy delivery invoice noted resident #4's Clonidine 0.2 MG medication was delivered to
the facility on [DATE] at 12:30 PM.
On 1/28/25 at 12:07 PM, the South Unit Manager checked resident #4's medical record and acknowledged
LPN B had not completed a Change Of Condition evaluation nor did the MAR show she administered the
as needed blood pressure medication as ordered by the nurse practitioner. The Unit Manager said she
expected nurses to complete the Change Of Condition form and LPN B should have documented any
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105904
If continuation sheet
Page 2 of 3
Printed: 05/28/2026
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
105904
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Atlantic Shores Nursing and Rehab Center
4251 Stack Blvd
Melbourne, FL 32901
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
medication that was administered. She said Clonidine 0.3 MG was available in the electronic medication
dispensary machine, and questioned that LPN B might have given the medication that was available but did
not document it.
On 1/29/25 at 12:19 PM, in a joint interview with Director of Nursing (DON) and Nursing Home
Administrator, the DON explained she expected nurses to monitor, follow up, and complete a Change In
Condition evaluation when the provider was notified of any concerns. She recalled on 12/12/24, resident #4
went to dialysis and stated, I believe he was acting up with the driver. She checked the medical record and
could not find any documentation that LPN B administered resident #4's additional order for blood pressure
medication nor monitored the resident after the nurse practitioner was notified. The DON conveyed that
LPN B may have administered the medication on hand of Clonidine 0.3 MG instead of 0.2 MG and
mis-transcribed the order. She said LPN B would be re-educated for the incident.
On 1/29/25 at 1:30 PM, the DON stated, there is no policy for change in condition.
Review of the Facility assessment dated [DATE] documented the facility provided care for residents with
combinations of conditions that require complex medical care and management, . Management of medical
conditions, Assessment, early identification of problems/deterioration, management of medical and
psychiatric symptoms and conditions .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105904
If continuation sheet
Page 3 of 3
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the January 29, 2025 survey of ATLANTIC SHORES NURSING AND REHAB CENTER?
This was a inspection survey of ATLANTIC SHORES NURSING AND REHAB CENTER on January 29, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ATLANTIC SHORES NURSING AND REHAB CENTER on January 29, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.