Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Boca Raton Rehabilitation Center during CMS and state inspections, most recent first.
A resident with chronic venous hypertension and a history of lower extremity thrombosis had a vascular surgery visit that resulted in a paper order for leg wraps, but nursing staff did not clarify the specifics of the order, did not enter it into the EMR, and did not document it in nursing notes. The RN Unit Manager acknowledged the existence of the paper order yet did not contact the physician for clarification on wrap type, size, compression level, or application schedule, and continued use of previously ordered kerlix wraps persisted. The cognitively intact resident reported that staff ignored his statements about the new compression wrap order and that he refused the kerlix wraps because they did not match the vascular surgeon’s instructions.
LPNs administered IV medications to a resident with complex medical needs without documented evidence of required IV therapy certification or training. Despite repeated requests, the DON did not provide certification records, training documentation, or access to relevant policies, and gave conflicting statements about LPN responsibilities. MARs confirmed that LPNs performed IV administration, but the facility failed to demonstrate compliance with state regulations.
Surveyors found that the facility did not provide necessary maintenance to ensure a sanitary, safe, and homelike environment. Observations included cluttered outdoor areas visible to residents, missing trash bins, defective lighting, missing mirrors, rusted screws, holes in doors and walls, and persistent ceiling leaks in common areas. Staff and residents reported these issues had been ongoing and unaddressed, with no clear timeline or documentation for repairs.
Surveyors found that two residents did not receive care according to physician orders: one received a nerve pain medication twice within an hour by two different nurses, and another did not have daily tracheostomy care documented as completed. Staff interviews and record reviews confirmed these failures to follow prescribed orders.
The facility did not maintain sufficient nursing staff on weekends over a three-month period, as confirmed by PBJ data and resident interviews. Multiple residents, including those requiring two-person assistance, reported delays in care and call light response due to low staffing. The Business Office Assistant acknowledged periods of understaffing, and staffing calculations showed repeated weekends with nursing hours per resident below required levels.
Surveyors found that the facility did not maintain infection control standards in the laundry and soiled utility areas, with unclean dryer drums, a broken lint trap, and a non-functional washing machine left unrepaired for weeks. Staff could not provide cleaning documentation, and soiled linens were improperly stored. A resident reported significant delays in receiving clean clothing due to the broken equipment.
A resident with severe protein-calorie malnutrition and a history of significant weight loss was not properly monitored or reassessed for nutritional needs after a substantial decrease in weight. The RD continued to use outdated weight data for nutritional calculations and did not complete required monthly assessments, despite the resident's ongoing feeding refusals and high nutritional risk status.
During a kitchen inspection, pureed turkey prepared for residents on a pureed diet was found to contain green particles from sweet relish, which did not meet the required smooth, uniform consistency. This issue was confirmed by both the Food Service Director and the speech-language pathologist, potentially affecting nine residents on a pureed diet.
Two residents did not receive the correct food portions or items as ordered on their meal tickets, despite care plans specifying dietary needs such as large portions and specific supplements. Observations showed missing food items and incorrect portion sizes, and one resident confirmed not receiving certain items. The Food Service Director reported that trays are checked for accuracy, but these deficiencies were still observed.
Surveyors found that food items in the kitchen, including thickened juice, fruits, pureed meat, lettuce, and tomatoes, were stored and served at temperatures above the required 41°F, and the walk-in refrigerator was operating at 50°F. Additional issues included unsanitary conditions such as a dirty cleaning bucket in the food production area and debris on the dry storage room floor. The Food Service Director and administrator were made aware of these deficiencies.
A resident with muscle weakness and hypertension, who was cognitively intact, was repeatedly observed in bed with the call light out of reach and, when accessible, found it was not functioning properly. A CNA confirmed the call light was not working as required and acknowledged the need for it to be both accessible and operational.
Failure to Clarify and Document Vascular Surgeon’s Leg Wrap Order
Penalty
Summary
The deficiency involves the facility’s failure to clarify, confirm, and document a physician’s order for leg wraps following a vascular surgery consultation, and to provide treatment in accordance with that order and the resident’s preferences. The facility’s own policy on physician orders requires unclear written orders to be clarified with the physician, documented as a clarification order in the medical record, and reviewed for accuracy. Resident #2, who was cognitively intact with a BIMS score of 15 and had diagnoses including chronic venous hypertension of both lower extremities and chronic embolism and thrombosis of a right lower extremity vein, had a documented appointment with a vascular surgeon. After this visit, there was no corresponding physician order entered into the electronic medical record (PCC) for the leg wraps allegedly ordered by the vascular surgeon. During interview, the RN Unit Manager acknowledged that there was a paper “leg wrap” order from the vascular surgeon but could not explain why it was not entered into PCC, nor could she provide details on the specific type, size, compression level, or application/removal times for the leg wraps. She also confirmed she did not call the physician to clarify the order and did not document the order in nursing progress notes or under electronic physician orders, despite stating that nurses are responsible for clarifying unclear orders. The resident reported that staff continued to use the same kerlix wraps ordered by a facility physician the prior year, rather than the compression wraps ordered by the vascular surgeon, and that staff did not listen when he tried to discuss the new order. He stated he refused the kerlix wraps because they were not the specific compression wraps ordered at the vascular surgery visit. No updated leg wrap order from the vascular surgeon visit was found in the record, and the next documented order pertained only to a follow-up outpatient rehab appointment.
Failure to Ensure LPN IV Therapy Certification and Documentation
Penalty
Summary
The facility failed to comply with State Law and professional standards regarding intravenous (IV) therapy administration by LPNs. According to Florida regulations, LPNs must complete a minimum 30-hour IV therapy certification course from a Florida Board of Nursing (FBON) approved provider before administering IV medications. Documentation reviewed by surveyors showed that LPNs administered Daptomycin IV to a resident with multiple complex diagnoses, including infection related to a knee prosthesis and MRSA, without evidence of the required IV therapy certification or training. During the survey, the Director of Nursing (DON) and staff were repeatedly asked to provide documentation of IV therapy certification, education, and training for all LPNs, as well as sign-in sheets for infection control and medication administration training. Despite multiple requests over two days, the DON failed to provide the requested documentation or electronic access to resident records. The DON gave conflicting statements, initially indicating that LPNs administered IV therapy, then later stating only RNs performed this task and that LPNs did not require certification. However, Medication Administration Records (MAR) confirmed that LPNs had documented administration of IV medications. Interviews with nursing staff further confirmed that LPNs independently administered IV medications to their assigned residents, and that documentation practices required the nurse who administered the medication to initial the MAR. No evidence was provided to show that LPNs had the necessary IV therapy certification, and the facility was unable to produce policies or training records as requested by the surveyor. The lack of documentation and inconsistent responses from facility leadership contributed to the identified deficiency.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by multiple observations and interviews. Surveyors observed that the back area visible to residents who smoke was cluttered with old furniture, metal filing cabinets, tarp-covered and uncovered boxes, and various paraphernalia, which remained unaddressed over several days. A resident reported that this area was not conducive to relaxation, describing it as appearing like trash was everywhere. Inside the facility, deficiencies included missing trash bins, defective lights, a missing mirror, and a rusted uncovered screw in resident bathrooms and rooms. Other rooms in the same section had the required amenities, indicating inconsistency in maintenance. Staff reported adapting to the lack of lighting and trash bins, and noted that holes in resident rooms had been present and reported, but not repaired. Further observations revealed holes in bathroom doors and behind beds, as well as ongoing ceiling leaks in the main dining room and short hall, which residents and staff stated had persisted for months without repair. Residents expressed frustration at the lack of response to their reports about these issues. The main dining room had been closed for ten months with no explanation provided, and work orders for the leaks were not produced when requested by surveyors. The Maintenance Director, who had recently started, stated he was still inventorying repairs, but no timeline or documentation was provided for addressing the deficiencies.
Failure to Follow Physician Orders for Medication and Tracheostomy Care
Penalty
Summary
Surveyors identified that the facility failed to follow professional standards of practice for medication and treatment administration for two residents. For one resident with muscle wasting, hypertension, and muscle disorders, a physician's order required Lyrica 150 mg to be administered every six hours for nerve pain. However, on a specific date, the medication was administered twice within one hour by two different nurses, as evidenced by the Medication Administration Record (MAR) and the Controlled Drug Declining Inventory Sheet. Both nurses confirmed in interviews that the physician's order was not followed regarding the timing and frequency of administration. For another resident with respiratory failure, malignant neoplasm of the supraglottis, dysphagia, and tracheostomy status, there was a physician's order for daily tracheostomy care, including cleansing the site with normal saline, patting dry, and covering with a drain sponge. Review of the MAR showed that from the first to the third of the month, there were no check marks or nurse initials to indicate that the tracheostomy care was performed as ordered. Staff confirmed that the absence of documentation meant the order was not followed.
Failure to Maintain Adequate Weekend Nursing Staff
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of every resident on weekends during the period from October 1, 2024, to December 31, 2024. Payroll Based Journal (PBJ) data for the first quarter of 2025 revealed that on twelve separate weekend dates, the ratio of nursing hours per resident fell below 1.0. Interviews with residents confirmed that staffing was insufficient, particularly on weekends and overnight shifts, resulting in delayed responses to call lights and assistance. One resident, who was cognitively intact, reported that it could take hours for staff to respond on weekends, and her spouse, who required two staff members to be moved with a lift, experienced longer wait times for assistance due to staff shortages. Another resident also reported that service could be improved on weekends, specifically noting a lack of sufficient staff. The Business Office Assistant confirmed that PBJ data is directly uploaded from the payroll system and acknowledged that there have been times when the facility was understaffed. The deficiency was substantiated by both resident interviews and PBJ staffing calculations, which demonstrated repeated instances of low staffing levels on weekends during the specified period.
Failure to Maintain Infection Control Standards in Laundry and Soiled Utility Areas
Penalty
Summary
The facility failed to maintain infection control standards in the Laundry Room and Soiled Utility areas, as evidenced by multiple observations and staff interviews. During a tour, one of two commercial dryers (Speed Queen) was found with its inner drum covered in thick, caked-on rust-colored and whitish substances, as well as melted debris, all of which came into direct contact with residents' clean clothing. Additionally, the Fagor dryer's lint trap filter basket was observed to be full, ripped, and caked with lint, with a broken metal bar hanging down, creating a potential fire hazard. Staff members, including laundry aides and the Housekeeping Director, were unable to provide information or documentation regarding the cleaning schedule for the dryer drums and lint traps, and acknowledged that these areas had not been cleaned regularly as required by facility policy. Further observations revealed that one of two commercial washing machines (Speed Queen) was non-functional and had been out of service for approximately thirty days, with visible rust and chipped areas. The facility had been operating with only one washing machine for over 100 residents during this period. Staff interviews confirmed the extended downtime of the washing machine and the lack of documentation or timely communication regarding its repair or replacement. The Housekeeping Director and Maintenance Director both acknowledged awareness of the malfunction but could not provide records of maintenance or cleaning activities. In the Soiled Utility Room, soiled linen was found improperly bagged and uncovered, exposing it to the environment. Interviews with staff and a resident confirmed delays in laundry services, with the resident reporting that it took more than a week to receive clean clothing and that she was told the delay was due to the broken washing machine. The facility's failure to follow its own infection control policies and procedures for laundry handling, equipment maintenance, and documentation led to the observed deficiencies.
Failure to Reassess Nutritional Needs After Significant Weight Loss in Tube-Fed Resident
Penalty
Summary
The facility failed to monitor and reassess the nutritional needs of a resident who was receiving tube feeding. The resident, who had a history of muscle weakness and severe protein-calorie malnutrition, experienced a significant weight loss of 22% over a four-month period. Despite this, the registered dietitian (RD) did not reassess the resident's nutritional needs after the new, lower weight was identified. The RD continued to use an outdated weight for nutritional calculations and did not address the substantial weight loss in subsequent nutrition notes. Additionally, the RD acknowledged in an interview that monthly nutritional assessments were not completed for this resident as required by facility policy. The resident was cognitively intact and expressed confusion about the need for tube feeding, indicating a lack of understanding or agreement with the intervention. The care plan identified the resident as being at high nutritional risk and in need of maintaining nutritional intake without significant changes. Staff interviews confirmed that the resident sometimes refused tube feedings, and there was a lack of documented reassessment or adjustment of the care plan in response to the resident's ongoing weight loss and feeding refusals.
Failure to Provide Proper Pureed Diet Consistency
Penalty
Summary
The facility failed to adhere to its policy for preparing pureed diets, as observed during a lunch tray line inspection. A container of pureed turkey intended for residents on a pureed diet was found to contain green particles, later identified as sweet relish added by the cook for flavor. The facility's policy requires pureed foods to have a soft, smooth, and uniform consistency without lumps or pieces, similar to mashed potatoes. Both the Food Service Director and the speech-language pathologist confirmed that the presence of these particles did not meet the required pureed diet consistency. This deficiency was identified during one of two main kitchen visits and had the potential to affect nine residents on a pureed diet out of a total census of 103 residents.
Failure to Provide Ordered Food Portions and Preferences
Penalty
Summary
The facility failed to provide food choices and preferences as ordered for two residents reviewed for nutrition. For one resident with hypertension and hyperlipemia, who was cognitively intact, a lunch tray was observed to be missing the large portion of pulled pork, plantains, and yellow rice as specified on the meal ticket. The resident's care plan indicated the need to provide diet and supplements as ordered, but the meal provided did not match the documented requirements. Another cognitively intact resident with chronic anemia and adult failure to thrive was observed at breakfast to have not received the fresh fruit cup and 8 ounces of milk as indicated on the meal ticket, nor the large portion of the main entrée. The care plan for this resident specified that weight gain would be favorable and that large portions should be provided. The resident confirmed not receiving the milk or fruit. The Food Service Director stated that trays are checked for accuracy by two staff members, but the observed deficiencies indicate that the correct portions and items were not consistently provided.
Failure to Maintain Food Safety and Sanitation Standards in Kitchen
Penalty
Summary
During two separate visits to the facility's main kitchen, surveyors observed multiple failures to store, prepare, distribute, and serve food in accordance with professional standards for food safety and sanitation. On the first visit, a bottle of thickened orange juice was found in the walk-in refrigerator with a used date over a month old, and the refrigerator's internal thermometer read 50 degrees Fahrenheit, exceeding the required maximum of 41 degrees Fahrenheit. Additionally, a yellow cleaning bucket with dark-colored water was present in the food production area, and several cups of fruit (strawberries, grapes, and canned pears) near the food tray line were measured at temperatures between 58.1 and 59.4 degrees Fahrenheit, all above the safe limit. The dry storage room floor was also observed to be covered with debris and food wraps. On the second visit, further deficiencies were noted during the lunch tray line. A cold container of pureed turkey meat was found at 44.5 degrees Fahrenheit, and metal containers of lettuce and sliced tomatoes were measured at 58.8 and 58.9 degrees Fahrenheit, respectively, all above the required 41 degrees Fahrenheit or below. The Food Service Director acknowledged the temperature issues and indicated an intention to return the affected items to refrigeration. The administrator was informed of these findings during an interview.
Failure to Ensure Accessible and Functional Call Light for Resident
Penalty
Summary
A deficiency was identified when a resident with muscle weakness and hypertension, who was cognitively intact, was repeatedly observed in bed with the call light placed on the floor and out of reach during multiple observations. The resident's medical record indicated recent admission and a mental status score confirming cognitive intactness. Despite being in bed, the resident did not have access to the call light, as it was not positioned within reach on several occasions. Further observation revealed that when the call light was eventually placed within the resident's reach, it was not functioning properly. Pressing the call light did not activate any light or noise outside the room or at the nurses' station, indicating a malfunction. A CNA confirmed during an interview that the call light was not working correctly and acknowledged that it should be both functional and accessible to residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 249 citations issued within 25 miles in the last 12 months — including the 6 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Boca Raton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avante At Boca Raton, Inc. | 0.5 mi | ★★★★★ | 16 | 0 |
| Willowbrooke Court At St Andrews Estates | 2.2 mi | ★★★★★ | 0 | 0 |
| Yamato Nursing And Rehabilitation Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Legacy At Boca Raton Rehabilitation And Nursing Ce | 2.6 mi | ★★★★★ | 0 | 0 |
| Stratford Court Of Boca Raton | 3.3 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Boca Raton Rehabilitation Center.
100% money-back within 48 hours.
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.