Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aviata At West Palm Beach during CMS and state inspections, most recent first.
A resident who was cognitively intact, on hospice, and documented as full code with a tracheostomy and feeding tube was found unresponsive by a CNA, who notified the assigned RN. The RN confirmed the resident had no respirations or vital signs but did not verify code status, assumed the resident was DNR because of hospice enrollment, and did not initiate CPR or call 911, instead contacting the physician and hospice. Another RN later saw on the electronic record that the deceased resident was full code, informed the first RN, but did not report the situation to administration. The facility’s abuse/neglect policy defined neglect as failure to provide necessary services and failure to report suspected neglect, and the failure to perform CPR on a full-code resident and to report the incident was determined to be neglect and Immediate Jeopardy.
A resident with documented full code status, including a care plan and physician order, was found unresponsive by a CNA, who notified the assigned RN. The RN assessed the resident, found no breathing or vital signs, but did not verify code status, did not initiate CPR, and did not call 911, instead assuming the resident was DNR because the resident was on hospice and contacting the physician and hospice. A second RN later observed on the computer that the resident was full code and informed the first RN but did not report the situation further. Facility policy required verification of advanced directives and initiation of CPR in the absence of a DNR, and leadership confirmed that these expectations were not followed, resulting in noncompliance with F678 related to basic life support and honoring advanced directives.
A facility failed to provide ordered wound care for several residents, complete weekly skin assessments, apply ordered compression stockings or Ace wraps for residents with edema, and administer Fosamax as ordered for one resident. Records, observations, and staff interviews showed repeated missed treatments, missing assessment documentation, residents without the ordered leg supports, and a MAR that documented daily Fosamax administration even though the medication was later identified as a weekly dose.
Failure to provide ordered pressure ulcer care. A resident with severe cognitive impairment had a facility-acquired unstageable sacral PU with necrotic tissue, and the care plan called for staff to administer ordered treatments and monitor effectiveness. Physician orders directed specific wound care, but during observation the dressing was undated and soiled, and TAR review showed wound care was missed on multiple occasions. The wound care nurse stated she did not complete the treatment on one missed day because she left early and said the Unit Manager was scheduled to do it.
A resident with CVA-related aphasia, dementia, and left elbow contracture was dependent for all ADLs and had orders for a restorative left elbow splint, but the record lacked additional ROM or splint interventions in the care plan. Staff observed contracted hands and fingers, and interviews showed a palm guard had been stopped due to a hand wound while a recommended T-bar for the other UE never arrived; staff did not follow up after the wound healed, and the restorative CNA reported no splint order was in the splint book.
A resident with COPD, low back pain, unspecified dementia, and osteoporosis had a fall with an L1 compression fracture, and the care plan and fall investigation listed a Reacher as an intervention. However, surveyors repeatedly found no Reacher in the room, the resident said she did not have one, and staff were unable to confirm its presence or whether it had been provided.
Failure to maintain aspiration precautions during tube feeding: A resident with a history of stroke, dysphagia, and severe cognitive impairment was observed twice lying flat in bed while enteral feeding was infusing, despite the care plan and facility policy directing head-of-bed elevation during and after feeding. An LPN, Wound Care Nurse, and Unit Manager were made aware of the resident’s position, and a family note above the bed also instructed staff to keep the head of bed elevated.
A resident with a tracheostomy and oxygen order was observed on the wrong O2 setting, and an LPN suctioned the resident without hyperoxygenating first or documenting post-procedure O2 status. Two other residents receiving nebulizer treatments had masks left hanging on the bed frame or post and touching the floor instead of being stored in a bag, and one resident and spouse reported the treatments were not being received as expected despite MAR documentation.
Insufficient staffing and missed weekend wound care: The facility did not meet its staffing plan on multiple weekends, with lower-than-required RN and CNA coverage. Three residents reported that wound care was not being provided on weekends, and one resident was observed with a leg dressing that had not been changed as ordered. The grievance log also included multiple complaints about delayed transfers, incontinence care, personal care, trach care, and wound care.
Medication was left at the bedside for two residents during med administration. One resident with no cognitive impairment had a cup with white capsules on the bedside table after receiving gabapentin, and another resident with severe cognitive impairment and Alzheimer’s disease had a small white pill found on the nightstand after an LPN administered meds; the pill could not be identified.
A resident receiving Valproic Acid for a mood disorder had no documented side effect or behavior monitoring in the MAR, TAR, or nursing notes. The resident had PTSD and moderate cognitive impairment, became emotional when discussing his history, and staff reported episodes of yelling, screaming, and refusing bathing, but the record lacked monitoring documentation.
Medication administration errors were identified for two residents when an LPN failed to give several ordered meds and inhalers to one resident during observation, while also documenting meds as given despite them not being administered. For another resident, the LPN observed 6 pills being given but the MAR documented 7, and the bottle for one documented vitamin was not found in the cart.
Sanitation and food safety deficiencies were observed in the kitchen and food service areas. Surveyors found sanitizer below the required concentration, peeling paint, damaged ceilings, dust and condensation on vents, residue on sanitized pitchers and a can opener, worn skillet coating, improperly stored plates, rust over the coffee maker, debris under equipment, a hole in the wall, mold around the ice machine door, and 16 cases of expired nutrition supplements. A Dietary Aide was also observed changing gloves without performing hand hygiene.
A resident with paraplegia and a history of recurrent UTIs did not receive prescribed monthly catheter changes or antibiotic therapy as documented in their care plan. Records showed no evidence of these interventions being provided or refused over several months. The resident later developed symptoms of infection, was evaluated by a provider, and was subsequently hospitalized for UTI and suspected urosepsis.
The facility failed to maintain sanitary conditions in the kitchen, with issues such as improper food cooling, personal items on prep surfaces, and inadequate hand hygiene. Observations included a personal cellular device on a prep table, food residue on equipment, and improper handling of food and drinks by staff.
A resident with multiple medical conditions, including end-stage renal disease and difficulty walking, did not receive timely toenail care, resulting in discomfort and the inability to wear shoes. Despite an order for podiatry care upon admission, the resident's toenails were long and painful, and staff interviews revealed a lack of clarity and follow-through regarding responsibility for nail care. The resident reported asking for assistance over two months without resolution, and a new podiatry consult was only ordered after a surveyor's interview.
A resident with Guillain-Barre Syndrome and other conditions requested ROM exercises to prevent weakness but did not receive them. Despite a physician's order for physical therapy, the resident had not received therapy or ROM exercises recently. The resident communicated her request to the MDS Coordinator, but no action was taken, and the Director of Rehabilitation was unaware of the request.
A resident with a PICC line was found to have an unchanged dressing since admission, despite facility policy requiring regular changes. The MAR inaccurately recorded dressing changes, which the DON confirmed did not occur, indicating a failure in maintaining sanitary conditions for the resident's PICC line.
A resident with ESRD and moderate cognitive impairment was not properly managed for fluid restrictions, leading to excessive fluid intake. Despite a care plan limiting fluids to 1000 ml per day, staff inconsistencies and communication gaps resulted in the resident frequently receiving more fluids than allowed. The situation was exacerbated by the resident's non-compliance and the facility's inability to effectively enforce the restrictions.
Failure to Honor Full Code Status and Initiate CPR for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s full code status and to provide ordered emergency care/CPR when the resident was found unresponsive. The resident was cognitively intact, had a tracheostomy and a feeding tube, required substantial/maximal assistance with activities of daily living, and was receiving hospice services. The resident’s care plan and physician’s orders documented an advanced directive of full code. Despite this, when the resident was found without chest rise and without vital signs, no CPR or emergency services were initiated. On the night of the incident, a CNA working the 11P–7A shift found the resident unresponsive during initial rounds and immediately notified the RN assigned to the resident. The CNA then continued with her rounds. The RN assessed the resident, determined that the resident was not breathing and had no vital signs, but did not check the resident’s chart or electronic record for code status. The RN assumed the resident was a DNR because the resident was on hospice, and therefore did not initiate CPR or call 911. Instead, the RN called the physician, who instructed her to call hospice, and hospice was notified. A hospice nurse was dispatched, and post-mortem care was provided. The RN documented that the resident was found with no chest rising and no vital signs, that hospice was called, and that post-mortem care was provided, but did not document any attempt at CPR. Another RN on the same 7P–7A shift returned from break around 12:30 AM and saw a hospice chaplain at the nurses’ station and the first RN charting. When he inquired, he was told that the resident had died. He observed on the computer screen that the resident was a full code and informed the first RN of this. Despite recognizing that the resident was a full code, he did not report the situation to anyone, continued his shift, and left the facility without notifying administration. The facility’s Regional Nurse Consultant later discovered, during chart audits of discharged residents, that no CPR had been performed on a resident with full code status and notified the Administrator. The Administrator, who also served as Abuse Coordinator, confirmed with the first RN that CPR and 911 had not been initiated. The facility’s abuse and neglect policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and included failure to report observed or suspected abuse or neglect as an example of neglect. The failure to perform CPR on a full-code resident and the failure of staff to report the incident to administration were identified as neglect. The Immediate Jeopardy began when the resident was found unresponsive and no CPR or emergency services were initiated, despite the resident’s documented full code status. The facility’s own review and interviews established that the RN responsible for the resident did not verify code status and acted on an assumption based solely on the resident’s hospice enrollment. Additionally, the second RN, after learning that the deceased resident was a full code, did not report the occurrence to administration or take further action. These inactions, in the context of the facility’s abuse and neglect policy and the resident’s clearly documented wishes and orders, led to the determination of neglect and Immediate Jeopardy related to failure to provide basic life support according to physician’s orders and advanced directives.
Removal Plan
- Provided individualized training to the involved registered nurse on the Florida Cardiopulmonary Resuscitation Policy, emphasizing steps to take when a resident is unresponsive.
- Suspended the involved registered nurse pending investigation.
- Terminated the involved registered nurse’s employment.
- Verified all current licensed nurses have active BLS/CPR certification cards.
- Conducted code blue drills, education, and post-testing for all licensed nurses.
- Completed an audit of Advanced Directive Discussion forms to ensure resident code status reflects and honors resident wishes.
- Held an ad hoc QAPI Committee meeting to review root cause analysis recommendations.
- Developed and initiated a Performance Improvement Plan based on the root cause analysis identifying failure to follow the Advanced Directive Policy and Procedure.
- Initiated code drills until all current nursing staff participated.
- Provided education to the second nurse who identified the code status regarding the importance of reporting the incident to facility administration.
- Initiated licensed nurse education on CPR policy and procedure, Advanced Directives policy and procedure, Abuse and Neglect, and the requirement to report neglect to administration, with post-testing and participation in code blue drills to validate competency.
- Educated all employees on the Abuse and Neglect policy and procedure, including reporting requirements.
Failure to Honor Full Code Status and Initiate CPR for Unresponsive Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide basic life support/CPR in accordance with a resident’s documented full code status and physician orders. Facility policy required that CPR be provided to all residents in cardiac arrest unless there was a fully executed DNR order, and that in the absence of such an order, the nurse must immediately begin CPR and continue until EMS assumed responsibility. The policy also required two nurses to verify resident identification and the presence of a fully executed DNR order in the advanced directive section of the medical record. In this case, the resident had a care plan and a physician’s order specifying full code status, and there was no documentation of a DNR order. Record review showed that the resident was cognitively intact, required substantial/maximal assistance with ADLs, had a tracheostomy and a feeding tube, and was receiving hospice services. The hospice nurse reported that the resident was alert, oriented, and personally chose to be full code, and that hospice honored residents’ decisions to remain full code. Despite this, when the resident was found unresponsive, the required verification of code status and initiation of CPR did not occur. A CNA working the night shift found the resident unresponsive at the start of her shift and immediately notified the RN assigned to the resident, then continued her rounds. The assigned RN stated that upon being notified, she assessed the resident around 11:15 PM, found no breathing and no vital signs, but did not check the chart for code status and did not initiate CPR or call 911. She reported that she assumed the resident was DNR because the resident was on hospice, and instead called the physician, who told her to call hospice, and then she called hospice. A progress note later documented that the resident was found with no chest rise and no vital signs, hospice was called, a hospice nurse was dispatched, and post-mortem care was provided. Another RN on the same shift stated that when he returned from break around 12:30 AM, he saw a hospice chaplain at the nurses’ station and observed the first RN charting; when told the resident had died, he saw on the computer that the resident was full code and informed the first RN of this, but he did not report the situation to anyone and continued his shift. The facility later identified that no CPR or emergency services were initiated for a resident with a full code order, and the resident died. The facility determined that Immediate Jeopardy began when the resident was found unresponsive and no CPR was initiated, and that the noncompliance involved failure to follow the advanced directive and CPR policies and procedures. Interviews with leadership confirmed that the expectation was for licensed nurses to follow facility policy and perform CPR in the absence of DNR orders, and that in this incident, those expectations were not met. The root cause analysis identified failure to follow the Advanced Directive Policy and Procedure as the cause of the noncompliance.
Removal Plan
- Provided individualized training to the involved registered nurse on the Florida Cardiopulmonary Resuscitation (CPR) Policy with emphasis on steps to take when a resident is unresponsive.
- Suspended the involved registered nurse pending investigation.
- Terminated the involved registered nurse’s employment.
- Verified that current licensed nurses have active BLS/CPR certification cards.
- Completed code blue drills, education, and post-testing for licensed nurses to validate understanding and competency.
- Completed an audit of Advanced Directive Discussion forms to ensure resident code status reflects and honors resident wishes.
- Held an ad hoc QAPI Committee meeting to review root cause analysis recommendations (including Medical Director participation) and obtained committee approval of recommendations.
- Developed and initiated a Performance Improvement Plan based on the root cause analysis, identifying failure to follow the Advanced Directive Policy and Procedure.
- Initiated code drills and continued until all current nursing staff participated.
- Provided education to the second nurse who identified the code status regarding the importance of reporting the incident to facility administration.
- Provided licensed nurse education on CPR Policy/Procedure, Advanced Directives Policy/Procedure, and Abuse/Neglect, with post-testing and required passing scores.
- Continued Code Blue Drills on each shift, with results reviewed in QAPI meetings to determine need for further drills and/or education.
- Assigned the Human Resources Generalist to monitor licensed nurses’ CPR cards to ensure active CPR certification and to verify CPR certification for all newly hired licensed nurses.
Missed wound care, incomplete skin assessments, and medication administration errors
Penalty
Summary
The facility failed to provide ordered wound care for multiple residents with non-pressure wounds. Resident #9, who had diabetes, morbid obesity, congestive heart failure, and a non-pressure chronic ulcer of the right lower leg, had a physician order for daily wound care, but the September 2025 TAR lacked documentation of wound care on several dates. During observation, a dressing was present on the lower right leg, and the resident stated the dressing was changed daily except on weekends. The DON and Wound Care Nurse reviewed the missing entries and agreed with the findings, and no refusal of treatment was located in the record. Resident #76, admitted with a right arm fracture, a left leg fracture, and morbid obesity, also had ordered wound care that was not completed as documented on multiple dates in August and September 2025. Observations showed dressings on the left leg, and the Wound Care Nurse clarified there was one wound to the left leg. Resident #110, who was cognitively intact, had physician-ordered daily wound care to both lower extremities, but the September 2025 TAR showed missed wound care on several dates. During observation, bilateral leg dressings were noted, and the resident stated the dressings had not been changed for four days. The DON and Wound Care Nurse reviewed the TAR and agreed with the findings. The facility also failed to complete weekly skin assessments as ordered for Residents #9, #76, #110, and #10. For Resident #9, the record showed a weekly skin sweep order, but the September 2025 TAR lacked the order and the last documented weekly skin assessment was dated 07/15/25. For Resident #76 and Resident #110, the TAR showed skin sweeps were marked complete on certain dates, but the corresponding Weekly Skin Integrity Review assessments were missing. For Resident #10, the record showed an order for weekly skin sweeps, but no skin assessments were documented during August 2025 even though the TAR was signed as completed. The Unit Manager stated the nurse documents weekly skin assessments on the assessment form and that new wounds should be documented there and reported to the doctor. The facility further failed to provide ordered edema-related supplies for Residents #76 and #110 and failed to administer medication as ordered for Resident #13. Resident #76 had an order for compression stockings, but observations showed no stockings being worn and the resident stated he had never been offered any special socks. Staff were unaware of the order until it was reviewed. Resident #110 had orders for compression stockings and later Ace wraps, but observations showed swollen legs without the ordered wraps or stockings, and the resident voiced concern about the lack of Ace wraps. For Resident #13, the physician ordered Fosamax, but the MAR showed it was administered daily from 09/12/25 through 09/23/25 even though the consultant pharmacist later identified it as a weekly medication that had not been filled or dispensed by the pharmacy. The DON reviewed the MAR documentation showing administration and noted the discrepancy.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for a resident with severe cognitive impairment and a facility-acquired sacral pressure ulcer. The resident was admitted to the facility with a quarterly BIMS score of 99 on a 0-15 scale, and the care plan identified skin impairment to the sacrum with a goal to promote healing through ordered treatments and monitoring. A wound care consultation documented an unstageable sacral pressure ulcer measuring 5.5 cm x 5.0 cm x 0.2 cm with 90% necrotic tissue. Physician orders directed staff to cleanse the sacral wound and apply Santyl with gauze and a silicone superabsorbent border dressing, then later to cleanse the wound, apply collagen and calcium alginate rope, and cover with a silicone superabsorbent border dressing. During observation, the wound care nurse removed a beige dressing that was not dated and was soiled with a moderate amount of serosanguinous drainage; redness was noted around the wound and the wound appeared quarter-sized with depth. Review of the August and September TAR showed wound care was not provided on multiple dates, including 08/08/25, 08/16/25, 08/19/25, 09/11/25, 09/12/25, and 09/23/25. The wound care nurse stated she did not provide wound care on 09/23/25 because she left early, and said the Unit Manager was scheduled to do it.
Failure to Provide ROM Devices for Resident With Contractures
Penalty
Summary
The facility failed to provide care and devices to maintain or improve range of motion for a resident with left elbow contracture and limited mobility. The resident was admitted with multiple diagnoses including anemia, CAD, DM, aphasia, non-Alzheimer's dementia, seizure disorder, respiratory failure, aphasia following CVA, dysphagia, GERD, and left elbow contracture. The most recent MDS showed the resident was dependent on staff for all ADLs and rarely or never understood. The resident had an order for a restorative left elbow splint to be worn 8 hours as tolerated, but the record contained no additional orders for ROM, devices, braces, or splints. The care plan for altered mobility/transfer status and the care plan for pain both documented goals, but neither included interventions to prevent contracture or further decrease in ROM. Observations showed the resident in bed with contracted hands and fingers, including the left hand folded at the base of the fingers and palm, and later the right hand contracted into a fist. Staff interviews indicated the resident had previously been on a palm guard for the left upper extremity and was supposed to have a T-bar for the right upper extremity, but the palm guard was discontinued due to a hand wound and the right-sided device never came in. The COTA stated staff did not follow up after the wounds healed and did not make additional attempts to obtain the right splint. The ADON stated therapy did not give the resident a splint and noted the resident had recurring water blisters. The restorative CNA stated there was no order in the splint book and no therapy order for such devices.
Failure to Provide Ordered Reacher After Fall and Compression Fracture
Penalty
Summary
The facility failed to provide a Reacher for a resident who had a history of chronic obstructive pulmonary disease, low back pain, unspecified dementia, and age-related osteoporosis without pathological fracture. The resident’s MDS showed a Brief Interview for Mental Status score of 14, indicating cognitive intactness, and Section GG showed substantial/maximal assistance was required for movement and care. The care plan documented an actual fall without injury and an alteration in musculoskeletal status with an L1 compression fracture, with interventions including keeping the call light within reach, maintaining the bed in the lowest position, and providing and encouraging use of a Reacher. Although the fall investigation form listed a Reacher as an intervention, survey observations on multiple occasions found no Reacher visible in the resident’s room or on the bedside table, and staff could not confirm that one was present. The resident stated she did not have a device to help retrieve belongings and said she used the call bell for assistance. PT and OT staff stated that a Reacher is provided if deemed necessary, but the resident’s PT and OT services had been discontinued and there was no recommendation for a Reacher in the record. Nursing and unit staff were unsure whether the resident had a Reacher, and the ADON confirmed responsibility for follow-up on the interventions.
Failure to Maintain Aspiration Precautions During Tube Feeding
Penalty
Summary
The facility failed to provide treatment and services to prevent complications of enteral feeding for one sampled resident by not ensuring aspiration precautions were followed during tube feeding. Resident #10 had a history of stroke and dysphagia, and the quarterly assessment documented severe cognitive impairment with a BIMS score of 99 on a 0-15 scale. The resident’s care plan identified a risk for aspiration related to stroke and dysphagia and directed staff to elevate the head of the bed during and after enteral feeding. The facility policy for enteral feeding also directed that the resident be assisted to a semi-Fowler position or turned on the right side. During observations, Resident #10 was found in bed lying flat on her back with the head of the bed completely flat while the enteral feed was infusing. This was observed at 9:15 AM and again at 10:55 AM on the same day. Staff K, LPN was notified after the first observation and later again after the second observation, and the Wound Care Nurse was also made aware of the resident’s flat position while feeding was infusing. A note posted by the family above the bed stated to ensure staff elevate the head of the bed 30 to 45 degrees to assist with breathing. During interview, Staff K stated the doctor said the resident’s head should be elevated 90 degrees due to risk of aspirating, and the Unit Manager was later brought to the room and informed the resident had been observed twice that morning with the head of the bed flat while the enteral feed was infusing.
Respiratory Care and Nebulizer Equipment Not Managed as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents receiving tracheal suctioning and nebulizer treatments. Facility policy for tracheal suctioning required hyperventilating the resident before suctioning and assessing and documenting the resident’s condition and response, while the nebulizer policy required evaluation of the resident and proper rinsing, air drying, and bag storage of the equipment in the resident’s room. For one resident with a tracheostomy, severe cognitive impairment, and orders for continuous oxygen at 2 liters per minute via tracheostomy, staff observed the resident on oxygen set at 4 liters per minute. During tracheal suctioning, an LPN removed the oxygen and suctioned the resident without first hyperoxygenating the resident, stating she forgot her pulse oximeter and forgot to hyperoxygenate before starting. The record did not show documentation of oxygen saturation or resident status after the suctioning, and the LPN stated she thought the resident was supposed to be on 2 liters. For two other residents receiving nebulizer treatments, nebulizer masks were observed hanging on the bed frame or bed post and touching the floor, rather than being stored in a bag. One resident had orders for scheduled and as-needed inhalation treatments and the spouse and resident stated the treatments had not been received as expected, although the MAR documented administration. The other resident also had orders for inhalation treatments, and the nebulizer mask was repeatedly observed hanging on the bed post without proper storage despite documentation that treatments had been given.
Insufficient Staffing and Missed Weekend Wound Care
Penalty
Summary
The facility failed to provide sufficient nursing staff on 6 of 13 weekends reviewed and did not follow its own facility assessment staffing plan. The assessment, revised 02/19/25, called for licensed nurse and CNA staffing ratios by shift, but weekend staffing records showed lower-than-planned coverage on multiple dates, including nurse ratios of 1:33.33, 1:25.25, and 1:25.75 on day shift, and CNA ratios ranging from 1:11.44 to 1:16.66 across day, evening, and night shifts. The report also noted 11 grievances related to patient care and services from April 2025 through the survey date, including complaints about staff issues, delayed transfers, delayed incontinence care, personal care concerns, and wound care concerns. During the initial pool process, three sampled residents stated their wound care was not being provided on weekends. An observation on 09/22/25 found Resident #76 with a dressing to the left leg dated Friday 09/19/25, even though the dressing was ordered to be changed daily. The report also documented grievances involving staff inability to transfer a resident back into bed timely, a resident waiting to be changed because a mechanical lift needed charging, improper incontinent care, care and services for a tracheostomy, personal care by a CNA, and lack of wound care by the nurses.
Medication Left at Bedside for Two Residents
Penalty
Summary
The facility failed to ensure standards of practice for medication administration for 2 of 27 sampled residents by leaving medications at the bedside. Resident #39, who had a BIMS score of 15 indicating no cognitive impairment, was observed sleeping in bed with a clear medication cup containing 2 white capsules on the bedside table. Later, the resident stated he had taken the pills and identified them as pain medication for his legs. Staff O, an LPN, stated she had given the resident his morning medications at 9:36 AM and denied leaving medication at the bedside, but the capsules were observed in the room after administration. The resident’s physician order showed gabapentin 100 mg, 3 tablets by mouth two times a day for neuropathy. Resident #14, who had a BIMS score of 5 indicating severe cognitive impairment and a diagnosis of Alzheimer’s disease, was observed during medication administration with Staff K, an LPN. After the medications were administered, a small white round pill was found on the resident’s nightstand and was verified by Staff K as a pill. The pill was removed from the room and taken to the medication cart, where the ADON also examined it, but the medication could not be identified even after reviewing the resident’s orders and prescribed medications. The pill was then disposed of properly.
Lack of Monitoring for Valproic Acid Side Effects and Behaviors
Penalty
Summary
The facility failed to monitor behaviors and side effects for a resident receiving Valproic Acid 500 mg three times daily for a mood disorder. The resident was readmitted with a diagnosis including PTSD, and the current MDS documented a BIMS score of 12, indicating moderate cognitive impairment. Review of the September 2025 MAR, TAR, and corresponding nursing progress notes showed no documented side effect or behavior monitoring for the Valproic Acid. During interview, the resident became emotional when discussing his PTSD, combat history, injuries, and family, and stated that talking about his history was a trigger. Staff interviews also reflected behavior concerns: an LPN stated behavior issues would be documented in nursing progress notes and a psychological evaluation requested, while a CNA reported the resident had declined bathing and yelled and screamed at her to get out of the room, after which she notified the nurse on duty. The ADON was informed of the lack of side effect and behavior monitoring and agreed with the findings.
Medication Administration Errors and Documentation Discrepancies
Penalty
Summary
The facility failed to ensure it was free of medication errors, with a reported medication error rate of 17.14% (6 errors) out of 35 opportunities for 2 of 4 sampled residents. For Resident #85, during medication administration observation, Staff K, LPN prepared 7 pills but stated that the resident’s Mometasone and Budesonide inhalers had not arrived from the pharmacy. The resident said he had not received his inhalers for a few days. Review of the physician orders and the medications administered showed that ordered medications were not given during the observed pass, including Docusate Sodium, Vitamin D, Fluticasone-Salmeterol inhalation aerosol, Mometasone Furoate inhalation aerosol, and Budesonide inhalation suspension. Staff K later acknowledged confusion about the inhalers and stated she did not administer a nebulizer treatment, and the resident stated he did not receive his inhalers the prior night. For Resident #42, during medication administration observation, Staff N, LPN verified that 6 pills were given, but the electronic record documented 7 pills administered. The timestamped documentation showed both Vitamin B1 and Vitamin B Complex were recorded as given, and when Staff N was asked to locate the Vitamin B Complex bottle, she was unable to find it in the cart. These observations and record reviews showed discrepancies between what was observed, what was documented, and what was available for administration.
Sanitation and Food Storage Deficiencies in Kitchen and Food Service Areas
Penalty
Summary
The facility failed to provide foods prepared in a sanitary manner and in accordance with professional standards for food safety. During the initial kitchen tour, the surveyor observed multiple sanitation and maintenance concerns in the kitchen and storage areas, including quaternary ammonia sanitizer in a red bucket measuring less than 200 parts per million, peeling paint on a wall in dry storage, a ceiling over reach-in freezer #2 that appeared damaged from water exposure, dust and condensation on air conditioning vents, residue from date stickers on cleaned and sanitized pitchers used to provide fluids to residents during meals, a hand washing sink that was not sealed to the wall, residue on the blade of the counter-mounted can opener, a skillet with worn Teflon coating, plates stored on a shelf in the hot holding area that were not inverted, and peeling paint with rust on the ceiling over the coffee maker. A Dietary Aide was also observed removing single-use gloves and putting on a new pair without performing hand hygiene, and stated she was not aware hand hygiene was needed when changing gloves. During the tour of the food service area, the surveyor found 16 cases of expired nutrition supplements on shelves by the entrance from the service corridor, with expiration dates ranging from 11/01/24 through 09/01/25. The same area also had debris accumulated under and behind the pellet warmer and under and behind the reach-in cooler, and there was a hole in the wall to the right of the hand washing sink. On the follow-up kitchen tour, the surveyor observed an accumulation of mold around the inside of the door to the ice machine in the food service area. The Dietary Manager acknowledged the findings during the tours.
Failure to Provide Prescribed Catheter Care and Antibiotic Therapy
Penalty
Summary
Facility staff failed to provide necessary care and services for a resident with paraplegia and a history of recurrent urinary tract infections (UTIs), who required monthly catheter changes and prescribed antibiotic therapy. Clinical record review showed that the resident was dependent on staff for personal hygiene, bathing, dressing, and toileting, and had an indwelling urinary catheter. The care plan included approaches to minimize infection risk, such as administering antibiotics as ordered and performing monthly catheter changes. However, review of medication administration records and progress notes revealed no evidence that the resident received the prescribed monthly antibiotic therapy or catheter changes over several months. There was also no documentation indicating that the resident refused these interventions. The resident experienced symptoms including pain on urination, cough, and bladder spasms, and subsequently requested to be seen by a provider. The provider noted a history of recurrent UTI, cloudy urine with sediments, and ordered diagnostic tests. Later that day, the resident was transferred to the hospital, where they were diagnosed with a UTI and suspected urosepsis, and admitted for medical management. Interview with the Director of Nursing confirmed the absence of documentation for both the antibiotic therapy and catheter changes, as well as any resident refusal of care.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and food service areas, as observed during a survey. During an initial kitchen tour, a personal cellular device was found on a prep table, and there was an accumulation of food residue on the sharpening stones of a slicer. Additionally, containers of barbecued pork and meatballs were improperly cooled, with temperatures recorded at 49 and 51 degrees Fahrenheit, respectively, from the previous day. The wall near the handwashing sink was damaged, and there was black residue inside the ice machine. In a follow-up kitchen tour, further deficiencies were noted. A dietary aide was observed adjusting glasses, using a personal cellular device, and handling food without performing hand hygiene. Ice from an unknown source was found in the handwashing sink, and another dietary aide was wearing loose-fitting bracelets while preparing food. Additionally, a dietary aide was seen handling portioned drinks with bare hands, directly contacting the lip surface of the cups. These observations indicate a failure to adhere to professional standards for food safety and sanitation.
Failure to Provide Timely Toenail Care
Penalty
Summary
The facility failed to provide timely toenail care for a resident who was admitted with multiple medical conditions, including end-stage renal disease, protein-calorie malnutrition, atrial flutter, bilateral non-pressure wounds of the lower extremities, anemia, hypertension, major depressive disorder, and difficulty walking. The resident, who was cognitively intact, required assistance with activities of daily living such as bathing, dressing, and footwear. Despite having an order for podiatry care upon admission, the resident's toenails were observed to be long and causing discomfort, with one toenail curving into the foot, leading the resident to wear sandals due to pain. Interviews with staff revealed a lack of clarity and follow-through regarding responsibility for toenail care. The MDS Coordinator indicated that the nursing staff was responsible, but there was no documentation of previous podiatry consultations. The resident reported repeatedly asking for nail care over two months without resolution. CNAs stated they would notify a nurse if they were unable to cut a resident's nails, and an LPN confirmed the ability to request a podiatry consult. However, no prior consults were documented, and a new order for podiatry was only written after the surveyor's interview with the resident.
Failure to Provide Requested ROM Exercises
Penalty
Summary
The facility failed to assess and provide Range of Motion (ROM) exercises as requested by a resident diagnosed with Guillain-Barre Syndrome, Type 2 Diabetes, Osteoarthritis, and Paraplegia. The resident, who had a Brief Interview for Mental Status (BIMS) score of 15, expressed concerns about becoming weaker without ROM exercises. Despite having a physician's order for a physical therapy evaluation and treatment, the resident had not received physical therapy, occupational therapy, or ROM exercises in the last seven days, as indicated in the Minimum Data Set (MDS). The resident communicated her desire for ROM exercises to the MDS Coordinator during meetings and when her family was present, but no action was taken. Interviews with facility staff revealed a lack of communication and follow-through regarding the resident's request for ROM exercises. The Director of Rehabilitation (DOR) was unaware of the resident's request and stated that a restorative aide typically performs ROM exercises. The MDS Coordinator acknowledged the resident's refusal to get out of bed and medication refusal but did not confirm if the resident had refused a rehab screening. The MDS Coordinator did not provide additional documentation to support the resident's care plan or refusal of services by the end of the survey.
Failure to Maintain Sanitary PICC Line for Resident
Penalty
Summary
The facility failed to maintain a PICC line in a sanitary manner for a resident, identified as Resident #375, who was admitted with acute osteomyelitis, a pressure ulcer, and a methicillin-resistant Staphylococcus aureus infection. Upon observation, the PICC line dressing was found to be dated prior to the resident's admission, and the resident confirmed that the dressing had not been changed since admission, although it was flushed. The facility's policy required the dressing to be changed 24 hours after insertion and weekly thereafter, or as needed if compromised. The Medication Administration Record (MAR) indicated that the dressing was marked as changed on three separate occasions, but the Director of Nursing (DON) acknowledged that these changes did not occur. This discrepancy between the MAR and the actual care provided highlights a failure in adhering to the facility's policy and physician orders regarding PICC line maintenance, leading to a deficiency in the standard of care provided to the resident.
Failure to Adhere to Dialysis Fluid Restrictions
Penalty
Summary
The facility failed to adhere to fluid restrictions for a resident who required dialysis care. The resident, who was moderately cognitively impaired, had a care plan that included a fluid restriction of 1000 ml per day due to End Stage Renal Disease (ESRD) and hemodialysis treatment. Despite these restrictions, observations revealed that the resident was frequently provided with fluids exceeding the prescribed limits. On multiple occasions, the resident was found with various beverages on the overbed table, including water, apple juice, coffee, and tea, which collectively surpassed the daily fluid allowance. Interviews with staff members highlighted a lack of consistent adherence to the fluid restriction protocol. Staff members reported that the resident often requested additional fluids and became upset when attempts were made to remove them. The Director of Nursing and other staff acknowledged the resident's non-compliance and the challenges in managing her fluid intake, noting that she would sometimes obtain fluids from the kitchen or vending machines. The Registered Dietitian emphasized the risks associated with fluid overload, including potential cardiac issues, but noted that the resident was previously more oriented and compliant with restrictions. The facility's failure to manage the resident's fluid intake effectively was compounded by communication gaps among staff. The kitchen staff, for instance, provided fluids without being aware of the resident's restrictions. This lack of coordination and oversight contributed to the resident's non-compliance with the prescribed fluid restrictions, posing a risk to her health due to potential fluid overload and related complications.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 142 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Palm Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At Greenacres | 2.2 mi | ★★★★★ | 5 | 0 |
| Beach Breeze Rehab And Care Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Darcy Hall Of Life Care | 2.7 mi | ★★★★★ | 4 | 2 |
| Aviata At Coral Bay | 3.2 mi | ★★★★★ | 0 | 0 |
| Palm Garden Of West Palm Beach | 3.4 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.