Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Beach Breeze Rehab And Care Center during CMS and state inspections, most recent first.
Surveyors identified improper sanitation practices in the kitchen, including dirty equipment and expired food items, as well as unsafe food storage temperatures in nourishment room refrigerators. The Food Service Director and Registered Dietitian confirmed these issues, which had the potential to affect all residents on oral diets.
Several residents were not treated with dignity and respect, including instances where a CNA was rude and accusatory, a resident was left without a gown after a colostomy incident, and staff were described as moody and disrespectful. Financial discussions were held publicly in the dining room, compromising resident privacy. During meals, a resident with cognitive impairment was physically stopped from eating with her hands, and another resident ate from others' plates before being served, with inconsistent staff response.
Persistent urine and stale odors were noted throughout multiple rooms and common areas, with additional maintenance issues such as oxidized faucets, broken cabinet doors, and a dirty air conditioner. The Housekeeping Manager could not provide documentation of deep cleaning or quality assurance completion, and acknowledged the need for more thorough cleaning after confirming the odors during a tour.
Insufficient staffing in the memory support unit resulted in multiple incidents where residents with severe cognitive impairment consumed food or beverages from other residents' plates or cups without staff intervention. Staff and resident interviews confirmed that the unit was often chaotic, especially on weekends, and that the available CNAs and activities staff were unable to adequately supervise all residents during meal times.
A resident with limited English proficiency and a history of stroke, dementia, and other conditions relied on a sign created by family to communicate preferences and needs. The sign was removed from the resident's room by an unknown individual, causing distress to the resident and spouse, and staff were unable to explain its removal. The facility failed to honor the resident's choice and did not support effective communication as outlined in the care plan.
A resident with no cognitive impairment reported receiving a cash disbursement from the business office without being provided a receipt or signing for the funds, contrary to facility policy. Staff claimed the resident signed the required forms, but could not explain the absence of witness signatures. Review of the documentation revealed signature discrepancies, and the resident denied signing the withdrawal receipt, indicating a failure to properly document and secure the resident's personal funds.
The facility did not provide a resident with her original documents upon request, despite having them available, and failed to ensure another resident received mail as required by policy. Both residents were cognitively intact, and staff interviews revealed inconsistencies in the mail distribution process.
A resident with moderate cognitive impairment and multiple health conditions, who smoked occasionally and required supervision, did not have a care plan addressing smoking despite facility policy and a completed assessment. Staff confirmed the resident smoked with supervision, but no care plan was present in the health record.
The facility failed to ensure that a resident with limited English proficiency and physical impairments had effective means to communicate with staff, as a communication board was inaccessible and translation support was inconsistent. Additionally, another resident managing her own colostomy experienced frequent delays in receiving necessary ostomy supplies, leading to improvised care and discomfort. Staff interviews revealed confusion over responsibilities for providing ostomy care, despite supplies being available.
A resident with dementia and a history of trauma expressed dissatisfaction with the activities provided, stating they were boring and not aligned with her interests, such as playing the piano. Despite repeated requests and staff awareness of her preferences, a policy change prevented her from leaving the memory support unit to access the piano, resulting in unmet psychosocial needs.
A resident with a terminal diagnosis and cognitive impairment was admitted to Hospice with a DNR order, but the facility's EMR and care plan listed the resident as full code. Staff were unaware of the DNR order in the Hospice paperwork, and there was no documentation of communication with Hospice or the resident's representative regarding code status, resulting in contradictory records.
A resident with severe cognitive impairment and a known fall risk experienced a fall that was witnessed by a roommate, but the incident was not reported or documented by staff. Despite the roommate informing staff and administration, there was no record of the fall in the resident's medical records or fall risk assessments, and staff interviews confirmed a lack of awareness and reporting of the event.
A resident dependent on tube feeding did not receive the prescribed amount of Jevity 1.5 via G-tube, as staff failed to initiate and maintain the feeding according to physician orders. Observations and staff interviews confirmed that the enteral nutrition was not started in the morning and was not supplemented to meet the required daily volume, resulting in the resident not receiving the full ordered nutrition.
A resident with COPD did not receive required respiratory assessments before and after nebulizer treatment, and was not provided a mouth rinse after inhaler use, as ordered. An LPN failed to check lung sounds, respirations, or oxygen levels during medication administration, and documented assessments that were not performed. The DON confirmed these assessments should have been completed as per orders.
A resident with no cognitive impairment and on a regular diet did not receive the required protein portion with their dinner, despite the meal ticket specifying chicken as the entree. The omission was not addressed at the time, and the Food Service Manager could not explain why the protein was missing, attributing it to an oversight.
The facility did not maintain an accurate and current Facility Assessment, repeatedly providing outdated documents that listed former staff and referenced expired COVID-19 guidance. Despite multiple attempts during the survey, the assessment continued to contain inaccuracies regarding the governing body and operational details, failing to meet regulatory requirements for annual review and updates.
Sanitation and Food Storage Deficiencies in Food Service Areas
Penalty
Summary
Surveyors observed multiple sanitation and food safety deficiencies during a tour of the facility's main kitchen and nourishment rooms. In the kitchen, several pieces of equipment, including two ovens, a steamer, and a meat slicer, were found with brown residue and debris, indicating inadequate cleaning. Additionally, a stack of sheet pans used for preparing chicken and fish was heavily soiled. The walk-in refrigerator contained expired food items, including butter, Swiss cheese, and a container of Mighty Shake, all past their expiration dates. In the nourishment rooms, the East wing refrigerator was found to be operating at temperatures significantly above the required 41°F, with readings of 58°F and 54°F on separate occasions. This refrigerator contained milk and other labeled food items. The thermometer's accuracy was questioned, but the temperature remained too high to ensure food safety. The Food Service Director and Registered Dietitian acknowledged these findings during the survey.
Failure to Honor Resident Dignity and Privacy During Care and Dining
Penalty
Summary
Multiple residents were not treated with dignity and respect by staff, as evidenced by direct resident interviews and observations. One cognitively intact resident reported that a CNA was consistently rude, accused her of lying, and failed to provide a clean gown after a colostomy bag incident, resulting in the resident sleeping without clothes. The same resident also reported that her food was discarded without being asked if she was finished. Another cognitively intact resident described staff as rude and unhelpful, becoming visibly upset during the interview. An anonymous resident, also alert and oriented, reported that CNAs were moody, arrogant, and disrespectful on both shifts, but declined to name staff due to fear of retaliation. The Social Service Director confirmed that such behavior did not reflect dignified treatment. A resident's financial matters were discussed in public areas, compromising privacy and dignity. The Business Office Manager delivered cash and discussed social security payments with a resident in the dining room, in the presence of other residents and staff. The resident requested documentation and privacy, but the Business Office Manager responded loudly and dismissively, refusing to move the conversation to a private setting. Another resident confirmed overhearing the loud financial discussion, stating it should have been conducted privately. The Business Office Manager admitted that forms were signed in the dining room, not in a private area. During meal observations, residents with cognitive impairments were not supported in a manner that preserved their dignity. One resident, who had severe cognitive impairment and a history of eating with her hands, was physically stopped by a CNA from eating with her hands, causing her to yell out. The CNA then attempted to encourage utensil use, despite the resident's established preference. In another instance, a resident with severe cognitive impairment ate from the plates of two other residents before being served her own meal. One of the affected residents appeared agitated and was provided a new meal, while the other was not. Staff acknowledged that such incidents occurred and that they typically provided a new tray when food was taken from another resident's plate.
Failure to Maintain Clean, Odor-Free, and Well-Maintained Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment on one of its units, as evidenced by persistent and pervasive odors, particularly urine and stale smells, throughout multiple rooms and common areas during the survey week. Observations documented strong and unpleasant odors in several resident rooms, bathrooms, and hallways over consecutive days. The Housekeeping Manager reported that deep cleaning was scheduled for each room at least monthly and that daily quality assurance rounds were conducted, but was unable to provide documentation or logs confirming the completion of these tasks. During a tour, the Housekeeping Manager acknowledged the odors and suggested that the floors might be the source, indicating a need for more thorough cleaning. Additional maintenance concerns were identified, including an oxidized faucet in a resident bathroom, a corroded faucet and broken cabinet doors in the dining room, and a visibly dirty window air conditioner with a black substance present. Photographic evidence of these issues was obtained and shared with the Regional Nurse Consultant, who agreed with the concerns. No specific residents' medical histories or conditions were detailed in relation to the deficiency, but the observations were made in both occupied and unoccupied rooms.
Insufficient Staffing Led to Unsupervised Resident Interactions During Meals
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents in the memory support unit, resulting in multiple incidents where residents consumed food or beverages from other residents' plates or cups without intervention. Observations revealed that one resident with severe cognitive impairment and a history of Alzheimer's Disease, dementia, and dysphagia repeatedly took and drank from other residents' cups in the dining area when no staff were present. Staff were only alerted to these incidents by the surveyor, after which the contaminated cups were discarded. Another resident with severe cognitive impairment was observed eating food from the plates of two other residents before being served her own meal, causing visible agitation in one of the affected residents. Only one of the affected residents received a replacement meal, while the other did not. Interviews with staff indicated that the unit was typically staffed with three or four CNAs for 32 residents, and staff reported difficulty supervising all residents, especially when providing care in individual rooms. Staff from the activities department were noted to assist with supervision, but only one activities staff member was present at a time, making it challenging to monitor both dining rooms simultaneously. Staff consistently reported that more personnel were needed to adequately supervise and assist residents, particularly those with behavioral issues or cognitive impairments. A resident interview described the environment on weekends as chaotic due to insufficient staffing, further corroborating the observations and staff statements. The lack of adequate supervision directly contributed to the incidents where residents consumed food or beverages from others' plates or cups, and to the overall disorder in the unit, affecting the quality of care for all residents in the memory support unit.
Failure to Support Resident Communication Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not supporting the resident's choice to have a sign displaying personal preferences, dislikes, and family contact information posted in the resident's room. The resident, who was Spanish-speaking and assessed as cognitively intact with a BIMS score of 13, relied on the sign for communication due to a language barrier and limited English proficiency. The sign, created by the resident's family, was observed over the resident's bed but was later removed by an unknown individual. The resident and his spouse, both with limited English skills, expressed distress over the removal, stating that the sign was essential for communicating needs to staff. Interviews with facility staff, including the Social Services Director, DON, and Administrator, revealed that none of them knew who removed the sign or why it was taken down. The resident reported that the sign was not removed by direct care staff, but could not identify the person responsible. The care plan for the resident included interventions to address communication barriers, such as providing a translator and evaluating alternative communication methods, but did not address the removal of the sign. The lack of communication and failure to support the resident's expressed preference led to the deficiency.
Failure to Provide Proper Receipts and Documentation for Resident Personal Funds
Penalty
Summary
The facility failed to properly manage and document a resident's personal funds in accordance with its own policy, which requires that residents receive and sign a receipt for any cash or check disbursements, with a copy provided to both the resident and facility records. A resident with no cognitive impairment reported receiving $100 in cash from the Business Office Manager without being given a receipt to sign or a copy for his records. The resident stated he did not understand the reason for the cash disbursement and did not recall signing any documentation for the transaction. When questioned, the Business Office Manager and Marketing Manager both claimed the resident had signed the required forms, but could not explain why they did not sign as witnesses, as required by policy. Upon review, the Administrator noted discrepancies in the signatures on the withdrawal receipt and other documents, agreeing that one of the signatures did not match the resident's usual signature. The resident also denied signing the withdrawal receipt and stated that the signature on the document was not his. The facility's failure to ensure proper documentation and witness signatures during the disbursement of personal funds resulted in a lack of compliance with established policy and created confusion regarding the handling of the resident's finances.
Failure to Provide Original Documents and Deliver Mail to Residents
Penalty
Summary
The facility failed to provide a resident with her original documents upon request and failed to deliver mail to another resident as required by policy. In the first instance, a resident with no cognitive impairment requested her original documents from the Office Manager, expressing concerns that the provided copies were incomplete and altered. Despite the resident's request, the Business Office Manager only provided a copy, stating that the resident should have received the originals from the Department of Children and Families (DCF), and did not directly address the resident's request for the originals, even though original forms were available in the office. In the second instance, another resident, also with no cognitive impairment, reported not receiving any mail and was unaware of the mail distribution process. Interviews with staff revealed that mail addressed to residents is sorted by the receptionist and distributed by the activities staff. However, the process for determining whether mail addressed to both the resident and the facility should go directly to the resident or to the business office was inconsistently described, potentially leading to residents not receiving their mail as intended.
Failure to Develop and Implement Smoking Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's smoking needs, despite policy requirements that any smoking-related privileges, restrictions, and concerns be documented in the care plan. The resident in question was moderately cognitively impaired, required assistance with mobility and transfers, and had multiple diagnoses including cancer, chronic lung disease, malnutrition, and muscle weakness. A smoking evaluation indicated the resident required supervision and assistance to light or extinguish cigarettes. Record review revealed that no care plan for smoking was present in the resident's electronic health record, even though the resident reported smoking occasionally and staff confirmed that the resident smoked under supervision. The absence of a care plan was acknowledged by the Regional MDS Coordinator, who noted that an assessment had been completed but a care plan was not generated as required.
Failure to Provide Communication Supports and Ostomy Supplies
Penalty
Summary
The facility failed to provide appropriate means for a resident with communication barriers to effectively communicate with staff. One resident, who was Spanish-speaking and had limited use of his right arm and hand due to multiple medical conditions including stroke and muscle weakness, was unable to access a communication board that was placed on the right side of his bed, out of his reach due to raised bed rails. The resident's care plan identified a potential communication problem and included interventions such as providing a translator and evaluating alternate communication methods, but these were not effectively implemented. Interviews revealed that while some staff and therapists spoke Spanish, there was no assurance that communication needs were met when Spanish-speaking staff were not present, and the resident expressed frustration over the removal of a sign created by his family that helped communicate his needs. Another deficiency involved the facility's failure to ensure a resident with a colostomy had timely and consistent access to necessary ostomy supplies to independently maintain her ostomy care. The resident, who was cognitively intact and managed her own colostomy, reported frequent delays in receiving replacement ostomy bags, sometimes resorting to using zip-loc bags overnight when supplies were not provided. She also reported skin irritation due to these delays. Interviews with staff revealed confusion regarding responsibility for providing colostomy care and supplies, with nurses and CNAs each indicating the other was responsible. The central supply coordinator confirmed that supplies were available and accessible to nursing staff, indicating the issue was not due to a supply shortage. Both deficiencies were substantiated through interviews, observations, and record reviews, demonstrating that the facility did not ensure residents maintained their ability to perform activities of daily living, such as communication and ostomy care, due to failures in providing necessary supports and supplies as outlined in their care plans.
Failure to Provide Resident-Centered Activities in Memory Support Unit
Penalty
Summary
The facility failed to provide activities that met the interests and psychosocial needs of a resident with a history of dementia, mood disturbance, anxiety, and trauma. The resident, who had moderate cognitive impairment and was dependent on staff for emotional, intellectual, physical, and social needs, expressed dissatisfaction with the activities offered, describing them as boring and not aligned with her interests. She specifically stated a preference for crossword puzzles and music, and repeatedly requested access to a piano, reflecting her background as a former piano teacher. Despite these expressed preferences, the resident was observed participating in activities she found unengaging, such as watching TV and folding washcloths, and was often seen asleep in common areas. Staff interviews confirmed that the resident previously enjoyed playing the piano when she was in the general population, but a recent corporate policy change restricted residents in the memory support unit from leaving the unit, preventing her from accessing the piano located outside the locked area. Staff acknowledged the resident's interest in the piano but stated they were not permitted to escort her outside the unit. The resident's daughter also confirmed that her mother frequently requested to play the piano during visits. These actions and inactions resulted in the facility not providing activities tailored to the resident's interests, thereby failing to promote her psychosocial well-being.
Failure to Collaborate with Hospice on Code Status Documentation
Penalty
Summary
A deficiency occurred when the facility failed to ensure proper collaboration with Hospice services regarding a resident's code status, resulting in contradictory documentation. The resident, who was cognitively impaired and had a terminal diagnosis, was admitted to Hospice services with a documented DNR (Do Not Resuscitate) order in the Hospice paperwork. However, the facility's electronic medical record (EMR) and care plan listed the resident as a full code, and current orders reflected this status as well. Discontinued orders and Hospice documentation indicated a DNR status, but this was not consistently reflected in the facility's records. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's correct code status. The RN relied on the EMR banner for code status information and was unaware of the DNR order in the Hospice paperwork. The Unit Manager and DON were also unaware that the DNR order had been provided by Hospice and could not recall or explain changes made to the code status in the EMR. There was no documentation of communication with the Hospice provider or the resident's representative regarding the code status, and staff could not provide a clear process for updating code status upon changes in care, such as admission to Hospice.
Failure to Report and Document Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to implement proper protocol following a resident fall. Record review showed that a resident with severe cognitive impairment and a history of impaired mobility and generalized weakness was not reported as having fallen, despite a care plan identifying fall risk. The resident's roommate reported witnessing the fall and stated that it took staff some time to respond, and that she informed both staff and administration about the incident. However, there was no documentation of the fall in the resident's records, and the fall risk assessment did not reflect any recent falls. Interviews with staff, including the nurse on duty and the DON, revealed that they were unaware of the fall and had not received any reports about it. The DON confirmed that staff are required to report falls in writing, but no such report was found. The lack of documentation and follow-up after the fall indicates that the facility did not ensure adequate supervision or accident reporting as required by protocol.
Failure to Administer Ordered Enteral Nutrition via G-Tube
Penalty
Summary
The facility failed to provide enteral nutrition as ordered for one resident who was dependent on tube feeding for nutritional support. The resident, who had multiple diagnoses including cancer, dementia, and was assessed as rarely or never understood, had physician orders for Jevity 1.5 to be administered via G-tube at 60 ml/hr for a total of 1200 ml over 20 hours daily. Observations revealed that the tube feeding was not initiated in the morning as ordered, with no supplement present in the resident's room during multiple checks. Staff interviews confirmed that the tube feeding was routinely stopped after the 1200 ml was infused, and not restarted until the next scheduled session, rather than running continuously for the prescribed 20 hours. Further review showed that the resident did not receive the full volume of enteral nutrition as ordered, as the feeding was not started until the afternoon and was not supplemented to meet the total daily requirement. Staff acknowledged that the feeding was paused for ADL care but did not adjust the schedule to ensure the resident received the full prescribed amount. These actions resulted in the resident not receiving nutrition via enteral method as ordered, constituting a failure to follow physician orders and provide appropriate care for a resident with a feeding tube.
Failure to Perform Required Respiratory Assessments During Medication Administration
Penalty
Summary
A deficiency occurred when a resident with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD) did not receive appropriate respiratory assessments as required by physician orders during medication administration. The resident, who was cognitively intact, had active orders for Albuterol nebulizer treatments and Symbicort inhaler, with specific instructions to check lung sounds, pulse, and respirations before and after nebulizer administration, as well as to rinse and spit after inhaler use. During a medication pass observation, the LPN administered oral medications, the inhaler, and the nebulizer treatment but failed to check lung sounds or assess respirations before or after the nebulizer treatment. Additionally, the resident was not provided water to rinse and spit after the inhaler, as required by the order. When interviewed, the LPN acknowledged that she should have performed the respiratory assessments and checked oxygen levels but forgot due to nervousness. Documentation in the record indicated that the LPN had charted the assessments despite not performing them. The DON confirmed that the expected practice was to assess lung sounds, oxygenation, and respirations before and after respiratory treatments and agreed that the LPN did not follow the required procedures for this resident.
Failure to Provide Complete Meal per Resident's Dietary Needs
Penalty
Summary
A deficiency occurred when a resident did not receive all the food items listed on their meal ticket, specifically the protein portion, during a dinner service. The resident, who was cognitively intact with a BIMS score of 13 and on a regular diet per physician order, received a tray containing mashed potatoes, green peas, and sliced bread, but no protein. The resident reported this to staff and requested an alternative (a peanut butter and jelly sandwich), but did not receive it. The Food Service Manager was unable to provide a clear reason for the omission and confirmed that the meal ticket indicated the resident should have received chicken as the protein. Further investigation revealed that the resident had a known dislike for beef due to difficulty digesting it, but did not have a dislike for pork and typically received fish as a substitute when needed. The Food Service Manager acknowledged familiarity with the resident's dietary preferences but could not explain why the protein was omitted from the meal. The omission was attributed to being overlooked, as confirmed by review of the meal ticket and staff interviews.
Failure to Maintain Accurate and Timely Facility Assessment
Penalty
Summary
The facility failed to review and update its Facility Assessment accurately and in a timely manner, as required by regulations. During the annual recertification survey, the Administrator provided a copy of the Facility Assessment that was outdated, listing former staff members—including the Administrator, DON, Medical Director, Medical Records staff, Social Services Director, and MDS Coordinator—who were no longer employed at the facility. The assessment also contained outdated information regarding the COVID-19 pandemic, referencing the federal Public Health Emergency that had already ended. When the surveyor pointed out these inaccuracies, the Administrator attempted to provide updated versions of the Facility Assessment. However, subsequent versions continued to include outdated information, such as references to the pandemic and incorrect documentation of the governing body and staff involved in the assessment. The Administrator acknowledged missing several areas that required updating and recognized the need for further revisions during the survey process. Throughout the survey, the facility was unable to present a current and accurate Facility Assessment that reflected the present staff, governing body, and relevant operational information. The repeated provision of outdated and inaccurate documents demonstrated a failure to conduct and document a comprehensive, up-to-date facility-wide assessment as required for both day-to-day operations and emergency preparedness.
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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 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 Coral Bay | 2 mi | ★★★★★ | 0 | 0 |
| Avante At Lake Worth, Inc. | 2.2 mi | ★★★★★ | 6 | 1 |
| Palm Beach Nursing Center | 2.3 mi | ★★★★★ | 13 | 0 |
| Aviata At West Palm Beach | 2.5 mi | ★★★★★ | 18 | 2 |
| Pine Trail Nursing And Rehab Center | 3 mi | ★★★★★ | 0 | 0 |
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