Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Boynton Beach Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with active medical devices, and did not maintain proper infection control practices for another resident with a drainage bag resting on the floor. Observations showed no EBP sign or PPE at the resident's doorway, and staff were not wearing gowns during direct care. The Infection Preventionist admitted the oversight, and the ADON acknowledged the issue with the drainage bag placement.
The facility failed to maintain a sanitary and safe environment, with issues such as peeling wallpaper, cracked floors, rust-laden furniture, and algae buildup on windows across resident units, therapy rooms, and the dining area. These deficiencies were confirmed with the Administrator and Director of Maintenance.
The facility failed to properly utilize the main dining room space during meal services, affecting 40 residents, most of whom were wheelchair-bound. Only half of the available space was used, leading to residents being moved from their tables to accommodate others, causing distress and complaints. The Director of Maintenance confirmed space constraints and the issue persisted over several days.
A resident in an LTC facility was unable to attend breakfast and therapy sessions on time due to staff failing to honor her requests for morning care and dressing. Despite being alert and oriented, the resident's preferences for waking and meal times were not accommodated, affecting her daily schedule.
The facility failed to provide ongoing activities for two residents with moderate cognitive impairment, both dependent on staff for activities. Despite documented interests in various activities, there was no recent documentation of participation or refusal, and observations showed the residents mostly in bed or sitting with the TV off. The Activities Director confirmed the lack of recent activity participation documentation.
A resident with a gastrostomy tube was inadequately supervised, leading to self-administration of fluids despite being on an NPO diet. The resident, with a history of acute respiratory failure and dysphagia, was found attempting to feed himself with milk, highlighting a lapse in supervision. Staff interviews indicated the resident often visited the dining room but was not observed eating, and he expressed feeling hungry due to insufficient food provision.
The facility failed to monitor the weights of two residents, leading to a deficiency in maintaining their nutritional status. One resident, with multiple health conditions, was not weighed according to policy, and staff inconsistencies led to a lack of accurate weight tracking. Another resident, with cognitive impairment, refused to be weighed, but there was no documentation of refusals or physician notifications. The facility's policy on weight measurements was not followed, resulting in a deficiency citation.
A resident with End Stage Renal Disease and Diabetes Type 2 experienced a deficiency in dialysis care, as they were not allowed to eat or drink during sessions despite being provided with a bagged lunch. The facility's Dietetic Technician was unaware of the issue, and the dialysis center's policy discouraged consumption during treatment. Additionally, dialysis communication forms were frequently incomplete, missing vital information about the resident's condition and treatment.
A facility exceeded the acceptable medication error rate, reaching 7.69% due to incorrect dosages given to a resident. An LPN administered 7.5 mg of Zyprexa instead of the prescribed 5 mg and gave 650 mg of Tylenol instead of 1300 mg. The errors were acknowledged by the LPN and confirmed by the DON.
The facility failed to provide necessary adaptive eating equipment for six residents, as observed during meal times. Despite documented needs for specialized utensils and cups due to conditions like hemiplegia and dysphagia, residents often received regular dining ware, hindering their ability to eat and drink independently. Therapy staff confirmed the oversight, highlighting a systemic issue in the facility's meal service.
A resident admitted for respite care had a blood glucose level of 438, exceeding the sliding scale insulin order parameters. The facility failed to notify the physician of this elevated level, contrary to standard practice. The DON confirmed that notifying the physician is standard when levels exceed 400.
Infection Control Lapses in EBP and Device Handling
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with active medical devices, including a central line, which is a requirement under the facility's infection prevention and control program. The resident, who was at risk for skin integrity issues, had active orders for treatments but no EBP orders were found upon record review. Observations revealed that there was no EBP sign or Personal Protective Equipment (PPE) at the resident's doorway, and staff were not wearing gowns during direct care. The Infection Preventionist acknowledged the oversight, admitting it was an error and that the resident should have been on EBP. Additionally, the facility failed to maintain proper infection control practices for another resident with a drainage bag. The resident's drainage bag was observed resting on the floor, which contradicts the Centers for Disease Control and Prevention's recommendations. The Preventionist was unaware of the policy regarding the placement of the drainage bag and did not provide a policy to justify the practice. The Assistant Director of Nursing (ADON) acknowledged the issue but noted the difficulty in keeping the bag off the ground due to the bed's position. These deficiencies highlight lapses in the facility's infection prevention and control measures, particularly in the implementation of EBP and the handling of medical devices. The lack of adherence to established protocols and the absence of clear policies contributed to the deficiencies observed by the surveyors.
Plan Of Correction
1. Resident's #1 orders for EBP (Enhanced Barrier Precautions) were immediately ordered and implemented. On supplies and signage were placed on door, and the bin for gowns was placed in the resident's room. 2. Resident's #3 bag was immediately changed. An audit was conducted by IPCO, of all residents with and to ensure they had orders for EBP (Enhanced Barrier Precautions). No others were identified. On an audit of all residents with was conducted by IPCO to ensure that no other residents with were on the floor. No others were identified. On the IPCO, ADON and nurse received one on one re-education by RCD regarding EBP for residents with and as outlined by the CDC. By nursing staff will be re-educated by DON/ADON/Designee on EBP for residents requiring it as outlined by the CDC. 3. Random audits to be conducted by DON or Designee 4 X a week for 4 weeks, then 2 times a week for 4 weeks, then weekly for 4 weeks, to ensure residents with and have orders for EBP (Enhanced Barrier Precautions) as outlined by the CDC. Random audits to be conducted by DON or Designee 4 X a week for 4 weeks, then 2 times a week for 4 weeks, then weekly for 4 weeks to ensure that residents with an that their bag is not touching the floor. 4. The QA & A/QAPI committee will review the results of the audits in the monthly QA & A Meeting for 3 months and as deemed necessary and make recommendations based on outcomes. QA & A/QAPI Committee will determine the need for further auditing beyond 3 months.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, safe, clean, and comfortable environment across multiple areas, including two resident units, the physical therapy room, and the main dining room. Observations revealed significant disrepair and cleanliness issues, such as peeling wallpaper, cracked and stained floors, rust-laden and stained over-bed tables, and broken furniture in the 200 Unit. The 300 Unit had soiled windows with algae buildup and a strong urine odor in the hallway. Additionally, community shower areas had inadequate privacy and non-functional light fixtures, while the nourishment room had a damaged door gasket. In the skilled therapy department, the parallel bars were heavily worn and broken, with non-slip strips needing replacement. The practice staircase was soiled and stained, and several ceiling tiles in the storage room and bathroom showed water damage. The main dining room had all windows soiled with heavy algae buildup. These findings were confirmed with the Administrator and Director of Maintenance, indicating a widespread failure in housekeeping and maintenance services necessary to ensure a safe and comfortable environment for residents.
Improper Utilization of Dining Room Space
Penalty
Summary
The deficiency observed in the facility pertains to the improper utilization of the main dining room space during meal services, affecting all 40 residents. During the lunch meal observation, it was noted that only half of the dining space was being used, despite the presence of 40 residents, 38 of whom were wheelchair-bound. This inadequate use of space led to residents being moved from their tables to accommodate others, causing distress and complaints among the residents. Staff members also acknowledged the difficulty faced by residents due to the constant repositioning during meals. Further investigation revealed that the main dining area measured 1200 square feet, while an additional connecting dining area, not being utilized, measured 560 square feet. The Director of Maintenance confirmed the issue of space constraints and the continuous movement of residents during meals. Observations on subsequent days confirmed the ongoing problem, with residents continuing to be moved and expressing dissatisfaction with the situation.
Failure to Honor Resident's Schedule Preferences
Penalty
Summary
The facility failed to honor a resident's right to choose her schedule, specifically regarding her preferred waking and meal times. The resident, who was alert and oriented, expressed her desire to attend breakfast in the Main Dining Room at 8:30 AM, but staff consistently delayed her morning care and dressing until 10 AM, despite her repeated requests. This delay also caused her to be late for her scheduled 10 AM therapy sessions. The surveyor observed the resident in her room at 8:30 AM, awake and in bed, confirming that her request to attend breakfast had not been fulfilled. The resident's clinical record indicated she was admitted with diagnoses including Dysphagia, Failure to Thrive, and a Lower Leg Wound. Her MDS assessment showed a BIMS score of 9, indicating non-cognitive impairment, and she was noted to be independent with eating. Despite these factors, the facility did not accommodate her preferences for waking and meal times, impacting her ability to attend meals and therapy sessions on time.
Failure to Provide Ongoing Activities for Residents
Penalty
Summary
The facility failed to provide ongoing activities for two residents, both of whom had moderate cognitive impairment and were dependent on staff for activities of daily living. Resident #62, diagnosed with dementia and stroke, was noted to have interests in sports, music, outdoor activities, conversation, movies/TV, and social events. Despite these interests, there was no documentation of participation or refusal of activities since June, and observations showed the resident mostly sleeping or sitting in a recliner with the TV off. The Activities Director confirmed the lack of recent activity participation documentation. Similarly, Resident #81, also diagnosed with stroke and having moderate cognitive impairment, was interested in similar activities and required assistance to participate. The last documented activity participation was in July, with subsequent notes indicating the resident was mostly in bed and not attending programs. Observations confirmed the resident was often in bed with the TV off. The Activities Director acknowledged the absence of recent documentation for this resident's activity participation.
Inadequate Supervision of Resident with Gastrostomy Tube
Penalty
Summary
The facility failed to adequately supervise a resident with a gastrostomy tube feeding, leading to a deficiency in ensuring the area was free from accident hazards and providing adequate supervision to prevent accidents. Resident #116, who was admitted with acute respiratory failure, dysphagia, and cognitive communication deficit, was observed self-administering fluids through his gastrostomy tube. Despite being on an NPO diet and having specific nutritional needs met through enteral feeding, the resident was found taking food from meal carts and hiding milk, indicating a lack of supervision and monitoring. On the day of the observation, the resident was seen lying in bed with a carton of milk, attempting to feed himself through the gastrostomy tube. The Director of Nursing intervened, but the incident highlighted a failure in the facility's supervision protocols. Interviews with staff revealed that the resident frequently visited the dining room, although he was not seen eating. The resident expressed feeling hungry and stated that staff did not provide enough food, prompting him to self-feed. This situation underscores the need for better supervision and adherence to dietary restrictions for residents with specific medical conditions.
Failure to Monitor Resident Weights
Penalty
Summary
The facility failed to adequately monitor the weights of two residents, leading to a deficiency in maintaining their nutritional status. Resident #89, who was admitted with multiple health conditions including diabetes and cognitive impairment, was not weighed according to the facility's policy. Despite being at risk for decreased nutritional status and dehydration, there were no orders for regular weight monitoring, and the resident's weight was not documented after the initial admission weight. Interviews with staff revealed inconsistencies in the process of recording and entering weights into the electronic health record, resulting in a lack of accurate weight tracking for Resident #89. Resident #32, who also had a history of cognitive impairment and other health issues, was not weighed consistently as required. The resident reportedly refused to be weighed, but there was no documentation of these refusals or any communication with the physician regarding the refusals. Despite the resident's care plan indicating a risk for decreased nutritional status, there was no recorded weight for several months, and staff failed to document any interventions or physician notifications related to the resident's refusal to be weighed. Observations noted that the resident appeared thin and had not been consuming meals adequately, yet there was no recent weight documentation to assess the resident's nutritional status. The facility's policy on weight measurements was not followed, as evidenced by the lack of consistent weight documentation and failure to report significant weight changes to the attending physician. Staff interviews highlighted a breakdown in communication and documentation processes, contributing to the deficiency in monitoring the residents' nutritional health. The facility's failure to adhere to its own policies and procedures for weight monitoring resulted in a deficiency citation during the survey.
Deficiency in Dialysis Care and Documentation
Penalty
Summary
A deficiency was identified in the care provided to a resident requiring dialysis services. The resident, who has End Stage Renal Disease and Diabetes Type 2, reported that during dialysis sessions, they were not allowed to consume food or drink, despite being provided with a bagged lunch by the facility. This issue had persisted for many months, and the resident had previously complained to the dialysis staff without resolution. The facility's Dietetic Technician was unaware of the issue until it was brought to their attention by the surveyor. Upon investigation, it was found that the dialysis center's policy discouraged eating and drinking during dialysis due to safety concerns, but allowed for consumption in the waiting room before or after treatment. However, the dialysis staff were not facilitating this for the resident. Additionally, the facility failed to ensure proper completion of dialysis communication forms, which are essential for documenting the resident's condition and treatment details. The forms, which should be completed by the dialysis center, were found to be incomplete on multiple occasions between July and October. These forms are crucial for recording pre- and post-dialysis weights, blood pressures, and other vital information. The surveyor confirmed these findings and discussed the issue with the facility's Director of Nursing, highlighting a lapse in communication and documentation between the facility and the dialysis center.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.69% due to two errors out of 26 opportunities. This affected one resident, who was administered incorrect dosages of Zyprexa and Tylenol. During a medication administration observation, a Licensed Practical Nurse (LPN) gave the resident one 7.5 mg tablet of Zyprexa instead of the prescribed 5 mg, following a gradual dose reduction order dated 10/02/24. The LPN acknowledged the error and noted that the 7.5 mg packet should have been returned to the pharmacy. Additionally, the LPN administered two 325 mg Tylenol tablets (totaling 650 mg) instead of the ordered two 650 mg tablets (totaling 1300 mg). The Director of Nursing confirmed these findings during an interview.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment and utensils for six residents who required them for nutritional support. Observations during meal times revealed that these residents did not receive the adaptive equipment as documented in their care plans and physician orders. For instance, Resident #40, who was supposed to receive beverages in 2-handled cups, was instead served in regular cups, making it difficult for the resident to drink independently. Similar issues were noted for other residents, such as Resident #57, who did not receive large grip utensils, and Resident #67, who was not provided with a mini-coated spoon. The clinical records and care plans for these residents clearly indicated the need for adaptive equipment to facilitate self-feeding and reduce spillage due to their medical conditions. Residents had diagnoses such as hemiplegia, dysphagia, arthritis, and muscle weakness, which necessitated the use of specialized utensils and cups. Despite these documented needs, the facility consistently failed to provide the necessary equipment during meal times, as observed by surveyors and confirmed by therapy staff. Interviews with the residents and therapy staff corroborated the observations, with residents expressing that they often did not receive the required equipment, which hindered their ability to eat and drink independently. The therapy staff acknowledged the oversight and confirmed that the residents had been assessed for the use of adaptive equipment. This deficiency in providing appropriate eating utensils and equipment was noted across multiple meal observations, indicating a systemic issue within the facility's meal service process.
Failure to Address High Blood Glucose Levels
Penalty
Summary
The facility failed to address high blood glucose levels for a resident admitted for respite care. The resident had an order for sliding scale insulin Novolog to be administered before meals and at bedtime, with a specific instruction to administer 2 units of insulin for blood glucose levels between 251-400. On a particular day, the resident's blood glucose level was recorded at 438, which exceeded the specified parameter. However, there was no documentation indicating that the physician was notified of this elevated blood glucose level. During an interview, the Director of Nursing stated that it is standard practice to notify a physician if blood glucose levels exceed 400, even if there is no explicit order to do so.
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.
Illustrative
What surveyors actually found near you
We read the 244 citations issued within 25 miles in the last 12 months — including the 5 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Boynton Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heartland Nursing & Rehab Center | 0.5 mi | ★★★★★ | 1 | 0 |
| Isles Of Boynton Nursing And Rehab Center | 2.7 mi | ★★★★★ | 9 | 0 |
| Boulevard Rehabilitation Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Hamlin Place Of Boynton Beach | 3.3 mi | ★★★★★ | 10 | 0 |
| Vi At Lakeside Village | 3.7 mi | ★★★★★ | 5 | 0 |
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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.