Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Cascades Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility was found to have unsanitary kitchen conditions, with multiple live and dead roaches, roach egg cases, and excrement observed in kitchen equipment, storage areas, and pantry cabinets. These findings were confirmed by health inspectors and acknowledged by facility administration.
A resident in the memory care unit with a history of wandering and exit-seeking was not properly assessed or consistently identified as being at risk for elopement. The care plan noted the resident should remain safe in a locked unit with increased supervision, but no elopement risk assessment was found in the chart. Staff later observed the resident attempting to exit through a window, becoming aggressive and yelling when redirected, and then being seen outside by a roommate’s window with the screen pushed out and the window partially open. Interviews showed staff were not consistently aware of the resident’s elopement risk, and the elopement binder system was incomplete.
A resident left the facility through an unsecured exit door, which had its alarm and magnetic lock deactivated, leading to a fall and serious injuries. The resident, who was cognitively intact, wheeled himself to a loading dock where he fell. Staff interviews revealed that the door opened without an alarm, and the maintenance technician confirmed the door was in maintenance mode, allowing the resident to exit undetected.
A resident exited an LTC facility through an unsecured door, leading to a fall and serious injuries. The door's alarm and lock were deactivated, allowing the resident to leave undetected. The resident, who had multiple medical conditions but was cognitively intact, wheeled himself to a loading dock and fell down steps, sustaining cervical spine injuries. Staff interviews revealed the door was in maintenance mode, allowing it to be opened without an alarm.
A CNA failed to follow proper perineal care technique for a resident being treated for a UTI. The CNA did not disinfect the overbed table before placing supplies and washed the resident's perineal area in an incorrect direction, contrary to facility policy. The DON acknowledged the improper technique.
The facility was found deficient in maintaining a sanitary and safe environment, with issues such as damaged electrical fixtures, broken furniture, inadequate privacy curtains, and soiled windows in resident rooms. The main dining room had worn tables and algae-covered windows, while the skilled therapy room had unstable equipment. Soiled utility rooms and public/staff bathrooms were also in disrepair, with uncovered trash and mold-like matter observed.
The facility was cited for numerous deficiencies in food safety and sanitation, including improper storage and handling of food, unsanitary conditions in kitchen areas, and failure to maintain appropriate food temperatures. Observations included torn refrigerator gaskets, mold, dust accumulation, and improper handling of utensils and cleaning equipment. Additionally, food items were not kept at required temperatures, posing potential health risks.
The facility was found to have infection control deficiencies in its soiled utility and laundry rooms. Uncovered biohazard containers and soiled light fixtures were observed in utility rooms, while the laundry room lacked a designated clean area, with dirty gloves on clean tables and debris in laundry baskets. These issues were acknowledged by the Regional Nurse Consultant.
A facility failed to respond adequately to a sexual assault allegation involving a resident with dementia. The incident, witnessed by a staff member, involved inappropriate touching by another resident. Although reported to the DON and SSD, there was insufficient documentation and follow-up on the affected resident's condition and psychosocial status. Immediate actions included separating the residents and placing the male resident on one-to-one supervision, but the psychiatric evaluation did not address the assault, and the SSD did not document follow-up after the resident's return from the hospital.
A resident with osteomyelitis completed their IV antibiotics, but the PICC line was not removed in a timely manner. Despite requests from the resident's spouse, the nursing staff did not contact the physician to discontinue the line, increasing the risk of infection. The Infection Control Preventionist noted that best practice is to remove the PICC line promptly.
The facility failed to provide adaptive eating equipment as ordered for two residents, leading to a deficiency in care. One resident, who required supervision for eating, was observed without the necessary built-up knife during meals. Another resident, who required setup assistance, was provided with non-curved utensils and a traditional knife, despite orders for adaptive equipment. Staff interviews revealed a lack of awareness and availability of the required tools, indicating a systemic issue in ensuring residents receive necessary assistance.
Unsanitary Kitchen Conditions Due to Roach Infestation
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, as evidenced by multiple observations of live and dead roaches, roach egg cases, and roach excrement in various kitchen and pantry areas. During inspections by the Department of Health, live roaches were found in the multi-function oven, floor stand mixer, Cambro unit, behind the reach-in cooler, dishwashing area, tilt skillet, wall behind the tilt skillet, 2-burner pot stove, and inside a paper towel dispenser. Additional findings included live and dead roaches, as well as roach excrement, in the pantry on the 400 unit, specifically on counters, in cabinets containing tubing and supplies, and under the sink. The facility's administrator was made aware of these concerns and acknowledged them during the inspection process. The Department of Health inspector confirmed the unsanitary conditions in the main kitchen as documented in his report.
Failure to Assess and Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to implement and follow appropriate interventions for a resident identified as being at risk for elopement. The resident was admitted to the memory care unit with diagnoses including metabolic encephalopathy and hypertensive urgency. Although the MDS showed a BIMS score of 15/15, the care plan documented exit-seeking behavior, a goal for the resident to remain safe and not attempt to exit without accompaniment, and interventions including increased supervision, admission to a locked unit, and distraction from exit seeking. The record also included a care plan for aggressiveness, violence, and yelling. No elopement risk assessments were found in the resident’s clinical record, despite the facility policy requiring assessment upon admission and when wandering or elopement behavior is observed. The resident told the surveyor that he wanted to go home to Thailand and did not wish to talk because he wanted to go back home. On the day of the incident, staff documented that the resident attempted to exit through a window, was not easily redirected, became aggressive and yelled, and was later observed outside by a roommate’s window with staff trying to redirect him back inside. The window screen was pushed outside and the window was partially open. Staff interviews showed inconsistent awareness of the resident’s elopement risk. An RN stated the resident was not at risk for elopement and said he was shocked by the attempt, while a CNA stated he was not aware the resident was at risk for elopement. The MDS Director stated an elopement risk assessment had been conducted, but she could not produce it when asked. The DON stated residents at risk for elopement were kept in binders at multiple locations, but during the tour only two binders were found, one binder did not include the resident on the list, and the third binder was not located.
Resident Elopement Due to Unsecured Exit Door
Penalty
Summary
The facility failed to protect a resident from neglect by not maintaining and securing exit doors, which led to a serious incident. A resident, who was cognitively intact with a BIMS score of 14/15, left the facility through an unlocked exit door. The door's alarm and magnetic lock had been deactivated, allowing the resident to exit undetected. The resident wheeled himself to the facility's loading dock, where he fell and sustained critical injuries, including fractures of the cervical vertebrae. Interviews with staff revealed that the door used by the resident opened easily without an alarm sounding. Staff members, including a registered nurse and certified nursing assistants, confirmed that they did not hear any alarms when the resident left the building. The maintenance technician stated that he checks the doors daily, but the door was found to be in maintenance mode, which deactivated the alarm and magnetic lock, allowing the resident to exit without detection. The facility's investigation revealed that the door's key code system had been compromised, and staff were using codes to access the door for routine tasks. The former administrator confirmed that the door was reactivated after the incident, but the lapse in security measures allowed the resident to leave the facility unsupervised, resulting in serious injury.
Removal Plan
- Johnson Controls, the company that installs and maintains the key code pad, cleared all historical code system data and recoded doors for safety and security.
- Johnson Controls changed maintenance code access. The community will not have access to the maintenance code.
- Security will round on the Health Center and activate multi-functional door alarm on Poinciana North daily.
- The Executive Director completed one to one education with Director of Plant Operations, Interim NHA, and Director of Nursing on the expectation that maintenance will check exit doors throughout the Health Center for security and functioning daily.
- The NHA, who is also the Abuse coordinator, and Director of Plant Operations began the education of Health Center maintenance team members and administration team members on the neglect policy. Health center maintenance team members will not be allowed to work until education is completed.
- There are 9 of 9 health center maintenance team members who have completed the neglect training. There are currently 11 administrative team members of which 10 have completed the neglect training and 1 is out on PTO and will be educated upon return.
Resident Elopement and Injury Due to Unsecured Exit
Penalty
Summary
The facility failed to provide adequate supervision and a secure environment, resulting in a resident exiting the facility and experiencing a fall with serious injuries. The incident occurred between 4:00 AM and 5:00 AM when the resident, who was in a wheelchair, exited through an unlocked door at the end of the 400-Hallway. The door's alarm and magnetic lock had been deactivated, allowing the resident to leave undetected. The resident then wheeled himself down a concrete walkway to a loading dock, where he fell down a set of three steps, sustaining serious injuries to his cervical spine. The resident involved had been admitted to the facility after hospitalization for a gastrointestinal hemorrhage and had multiple diagnoses, including malignant neoplasm of the prostate, anemia, acute respiratory failure, hypertension, adult failure to thrive, and physical debility. Despite these conditions, the resident was cognitively intact, as indicated by a Brief Interview for Mental Status score of 14/15. The facility's investigation revealed that the door's alarm system had been in maintenance mode, which allowed it to be opened without triggering an alarm. Interviews with staff members revealed that the resident was last seen at approximately 3:00 AM, and his absence was noticed at around 4:20 AM. Staff members reported that the door was found unlocked and could be opened without the alarm sounding. The facility's former administrator and the Director of Plant Operations confirmed that the door's maintenance mode was inadvertently activated due to a code similar to the one used by employees for regular access. This oversight allowed the resident to exit the facility without detection, leading to the fall and subsequent injuries.
Removal Plan
- Johnson Controls cleared all historical code system data and recoded doors for safety and security.
- Johnson Controls changed maintenance code access. The community (employees and security guards) will not have access to the maintenance code.
- Security will round on the Health Center and activate the screamer loud alarm on Poinciana North daily.
- The Executive Director completed one on one education with Director of Plant Operations, Interim NHA, and Director of Nursing on the expectation that maintenance will check exit doors throughout the Health Center for security and functioning daily.
- The NHA, who is also the Abuse coordinator and Director of Plant Operations, began education of Health center maintenance team members and administration team members on the missing person policy and exit door and alarm checks. Health center maintenance team members will not be allowed to work until education is completed. There were 9 of 9 health center maintenance team members who had completed this training. There are currently 11 administrative team members, of which 10 have completed this training and 1 is out on PTO and will be educated upon return.
Improper Perineal Care Technique Observed
Penalty
Summary
The facility failed to provide appropriate perineal care to prevent urinary tract infections (UTIs) for a resident. During an observation, a CNA was seen performing perineal care on a resident who was being treated for a UTI. The CNA did not disinfect the overbed table before placing supplies on it. While the CNA provided dignity and privacy to the resident, the technique used for cleaning the perineal area was incorrect. The CNA washed the resident's inner thighs and labia in an upward motion from back to front, which is contrary to the facility's policy that requires washing from front to back. The Director of Nursing (DON) confirmed that the CNA did not use the proper technique for perineal care. The facility's policy, dated February 2018, specifies that for female residents, the perineal area should be washed from front to back, with the labia separated and washed downward from front to back. The CNA's actions were inconsistent with these guidelines, leading to the deficiency noted by the surveyor.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment across multiple areas, including two residential units, public/staff restrooms, soiled utility rooms, the main dining room, and the skilled therapy room. Specific deficiencies included loose and damaged electrical fixtures, broken furniture, inadequate privacy curtains, and soiled windows in resident rooms. In the Gulfstream Unit, the community shower had a rusted handrail, and the nurses' station had soiled and rust-laden lockers. The main dining room had worn tables with exposed wood and sharp edges, and windows covered in a green algae-like substance. The skilled therapy room had old and unstable parallel bars and a worn exercise machine. The soiled utility rooms across different units were found with uncovered trash containers, biohazardous containers without lids, and dried brown matter on surfaces. The public/staff bathrooms had sink basins in disrepair with black mold-like matter around the drains. These observations were made during an environment tour and various inspections conducted by surveyors, accompanied by facility staff, including the Maintenance Supervisor, Housekeeping Supervisor, and Director of Skilled Therapy. Photographic evidence was obtained to document the deficiencies noted during the survey.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility was found to have multiple deficiencies in its food storage, preparation, and service areas, failing to adhere to professional standards for food service safety. During an inspection of the kitchen and food service areas, several issues were identified, including a torn door gasket on a walk-in refrigerator, peeling paint, and dust accumulation, all of which could lead to food contamination. Additionally, food items in the walk-in freezer were not properly covered, resulting in freezer burn, and the dish machine room had a significant build-up of dust and dirt. Other observations included improperly stored cleaning equipment, a moldy can opener, and uncovered bins of soiled linens in the food production area. Further inspection of the satellite kitchens revealed additional concerns. The Poinciana Satellite Kitchen had a floor drain covered with trash, soiled utility carts, and staff wearing inappropriate jewelry. The floor and walls were covered with mold, and dessert cups were handled unsanitarily. In the Gulfstream satellite kitchen, issues included mold in the cupboard area, unsanitary handling of silverware, and a dust-laden air-conditioning unit. The kitchen utility cart was soiled, and cleaning rags were improperly stored. The reach-in refrigerator gaskets were moldy, and the entrance door was in disrepair. Temperature control of food items was also problematic, with cold foods not maintained at the required 41 degrees or below and hot foods not kept at a minimum of 135 degrees. Specific instances included tossed salads and pureed succotash not held at appropriate temperatures, as well as milk, juices, and butter pats stored at higher than acceptable temperatures. These deficiencies indicate a systemic failure in maintaining food safety standards, potentially compromising resident health and safety.
Infection Control Deficiencies in Utility and Laundry Rooms
Penalty
Summary
The facility failed to maintain a sanitary environment in its soiled utility rooms and laundry room. During a tour of the facility's four soiled utility rooms, it was observed that biohazard containers were uncovered, exposing used sharp containers and biohazard bags. Additionally, an unidentified substance was found on the walls and ceilings, and the light fixtures were soiled with dirt and debris. In the laundry room, a dirty glove was found on the clean folding table, in direct contact with clean clothes. There was no designated clean area, as soiled laundry was sorted directly next to the washers, and the soiled laundry cart was stored on the opposite side of the four commercial washers. The laundry baskets were dirty with debris at the bottom, and the ceiling vents above the clean folding table were covered with dust and debris. These observations were acknowledged by the Regional Nurse Consultant.
Inadequate Response to Sexual Assault Allegation
Penalty
Summary
The facility failed to appropriately respond to allegations of sexual assault involving a resident with moderate cognitive impairment and dementia. The incident involved a male resident touching a female resident inappropriately, which was witnessed by a staff member. Despite the incident being reported to the Director of Nursing (DON) and the Social Service Director (SSD), there was a lack of thorough documentation and follow-up on the resident's condition and psychosocial status after the assault. The resident was sent to the hospital following a fall, but upon return, there was no documentation addressing the sexual assault. Interviews with staff revealed that the incident was reported, and some immediate actions were taken, such as separating the residents and placing the male resident on one-to-one supervision. However, the psychiatric evaluation conducted later did not address the sexual assault, and the SSD did not document follow-up actions after the resident returned from the hospital. The facility's response was inadequate in ensuring the resident's safety and addressing the psychological impact of the incident, as evidenced by the lack of comprehensive documentation and follow-up care.
Failure to Timely Discontinue PICC Line
Penalty
Summary
The facility failed to discontinue a Peripherally Inserted Central Catheter (PICC) line in a timely manner for a resident who had completed their course of intravenous (IV) antibiotics. The resident, who was admitted with osteomyelitis and had mild cognitive impairment, required substantial assistance with activities of daily living. An order for IV antibiotics was in place from April 20, 2024, to May 24, 2024. However, despite the completion of the antibiotics on May 24, 2024, the PICC line remained in place as of June 3, 2024. The resident's spouse had repeatedly requested the removal of the PICC line due to concerns about infection, but the request was not acted upon by the nursing staff. A registered nurse acknowledged the oversight and admitted to not contacting the physician to obtain an order for the removal of the PICC line. The Infection Control Preventionist confirmed that best practice dictates the removal of a PICC line as soon as possible to minimize infection risk.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment as ordered for two residents, leading to a deficiency in care. Resident #5, who was moderately cognitively impaired and required supervision or touching assistance for eating, was observed without the necessary built-up knife during meals. Despite having orders for adaptive equipment, including a built-up fork, spoon, knife, and plate guard, the resident was only provided with a built-up fork and spoon, and a traditional knife. Staff interviews revealed a lack of awareness and availability of the required adaptive equipment, indicating a systemic issue in ensuring residents receive the necessary tools for eating. Resident #15, also moderately cognitively impaired, required setup or cleanup assistance for eating and had orders for a built-up/curved fork, spoon, and rocker knife. However, during an observation, the resident was provided with a built-up fork and spoon that were not curved and a traditional knife. The resident expressed uncertainty about using the knife, regardless of its design, and staff confirmed the absence of built-up knives in the facility. Interviews with occupational therapists revealed that adaptive equipment was available but not utilized appropriately, further highlighting the facility's failure to adhere to care plans and orders. The deficiency was identified through observations, interviews, and record reviews, which demonstrated the facility's non-compliance with its policy on providing assistance with meals. The policy required that adaptive devices be provided to residents who need or request them, yet the facility did not ensure the availability and use of such equipment, impacting the residents' ability to eat independently and maintain adequate nutritional status.
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 262 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 Delray Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Abbey Delray South | 0.5 mi | ★★★★★ | 0 | 0 |
| Harbours Edge | 1.6 mi | ★★★★★ | 0 | 0 |
| The Terrace Of Delray Beach Nursing And Rehabilita | 2.1 mi | ★★★★★ | 0 | 0 |
| West Delray Nursing & Rehab Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Yamato Nursing And Rehabilitation Center | 3.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Cascades Health And 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.