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 Encore At Boca Raton Rehabilitation And Nursing Ce during CMS and state inspections, most recent first.
A facility failed to monitor and assess a resident's medication administration accurately, leading to a deficiency in quality of care. The facility did not adhere to its medication administration policy, failing to verify vital signs before administering medication. Additionally, the facility did not document vital signs as required by the doctor's orders, indicating a lack of reassessment and monitoring. Staff interviews revealed inconsistencies in managing changes in a resident's condition.
A facility failed to ensure adequate hydration and nutrition for a resident with good mental cognition and lactose intolerance. The registered dietitian recommended changing the resident's supplement to Ensure Clear, but there was a lack of documentation and monitoring of fluid intake by nursing staff. The multidisciplinary team did not evaluate the resident's nutrition related to medications, and the care plan lacked focus on fluid and nutrition maintenance. Interviews revealed staff did not recall monitoring fluid status, and the physician delayed fluid orders.
A facility failed to adequately monitor and assess medication administration for a resident, leading to a deficiency in care. The resident had orders for vital signs to be checked every shift, but documentation showed gaps in monitoring. Staff interviews revealed inconsistent understanding of procedures for managing changes in a resident's condition, contributing to the deficiency.
The facility failed to maintain food safety standards, with issues including a steamer leak, improper hand hygiene by a dietary aide, and inadequate cooling of pork roasts. The dietary aide was observed using improper glove hygiene and handling food contact surfaces with bare hands, leading to the need for re-sanitization of dishes. The CDM acknowledged these deficiencies.
The facility did not follow its Menu Planning policy, failing to provide the required daily servings of fruit as per national standards during one week of the Spring Summer Menu 2024 cycle. The Registered Dietitian acknowledged the shortfall, which affected the nutritional intake of all residents consuming meals prepared by the facility.
The facility failed to provide adequate access to call devices, functioning air mattresses, and wall lights for several residents. One resident was left in a soiled brief due to an unreachable call bell, while two residents had non-functioning air mattresses. Additionally, several residents faced issues with inaccessible wall lights, and one resident was unable to access the bathroom due to obstructions.
The facility failed to develop comprehensive care plans for residents with PTSD and did not implement interventions for monitoring side effects of psychotropic medications. Two residents with PTSD lacked care plans, and two residents on psychotropic medications were not monitored for side effects as required. Staff interviews revealed non-compliance with care planning policies, leading to deficiencies in resident care.
The facility failed to secure sharps and hazardous items, with an emergency cart left unlocked and a broken sharps container on a med cart. Two residents were found with sharps in their rooms, including a safety razor and scissors, posing safety risks. Staff were unaware of these hazards, and the facility's policy on sharps disposal was not effectively implemented.
A facility failed to maintain proper catheter care and dignity for a resident with an indwelling urinary catheter. Observations showed the drainage bag was often on the floor without a privacy cover, contrary to the facility's policy and the resident's care plan. The resident, who has paraplegia and neuromuscular dysfunction of the bladder, was cognitively intact and had requested monthly catheter changes. A CNA confirmed that catheter care should include hanging the bag with a privacy cover, but this was not consistently done.
The facility failed to monitor the intake of nutritional supplements for two residents, resulting in significant weight loss. One resident, with multiple health conditions, experienced a 13.01% weight loss due to inadequate documentation and monitoring of supplement intake. Another resident, with complex regional pain syndrome, also faced severe weight loss due to a lack of awareness and provision of recommended supplements. Staff interviews revealed a lack of understanding and documentation, contributing to the deficiency.
The facility failed to ensure proper respiratory care and infection control for residents. A resident was observed using oxygen without a physician's order, and respiratory supplies for four residents were not maintained to prevent infection. Observations revealed improper storage of nebulizer masks and outdated oxygen tubing. Interviews with residents and the DON confirmed lapses in following infection control protocols.
The facility failed to identify PTSD triggers for two residents, despite having a policy for trauma-informed care. One resident expressed dissatisfaction with care, and staff interviews revealed a lack of understanding and training. The social services staff did not create care plans addressing PTSD, citing a need to build rapport, while screenings did not address triggers.
The facility failed to accurately reconcile controlled substances for several residents, leading to discrepancies between medication administration records and controlled drug disposition sheets. This issue affected medications such as Percocet, Oxycodone, Temazepam, Morphine Sulfate, and Tramadol, highlighting a systemic problem in the facility's medication management process.
The facility reported a medication error rate of 12.50%, affecting two residents. One resident did not receive three scheduled medications, with one not ordered, while another resident's insulin pen was improperly primed. Staff B, an RN, admitted to documenting medications as administered when they were not and was shown incorrect priming techniques by another nurse.
The facility failed to secure medications properly, with instances of unsecured medications at residents' bedsides and an unlocked medication cart. Medications were improperly disposed of, with staff discarding pills in sharps containers instead of using the drug buster solution. Residents were found with medications without proper orders or evaluations for self-administration, highlighting issues with medication security and disposal practices.
The facility failed to provide meals that met the dietary preferences, allergies, and intolerances of six residents during dining observations. A resident with slight cognitive impairment did not receive the grits listed on her meal ticket, while another with hemiplegia received a tray missing specified items. A resident with intact cognition received a tray missing a fruit cup and diet ginger ale. A resident with moderate cognitive impairment received a tray missing sugar-free lemonade and ice cream. Another resident with moderate cognitive impairment received a tray missing crackers, mandarin oranges, and diet ginger ale. A cognitively intact resident did not receive a banana listed on the breakfast meal ticket, with grapes substituted instead.
A resident with paraplegia and neuromuscular dysfunction did not receive necessary adaptive eating equipment as prescribed, including a plate guard and spill-proof cups. Observations showed the resident's water and cups were out of reach, and the breakfast tray lacked the correct equipment. Staff interviews confirmed the oversight, and the facility's policy on adaptive equipment was not followed.
The facility's QAPI/QAA failed to implement effective corrective actions for repeated deficiencies in pharmacy services and assistive devices, specifically F755 and F810. These issues, previously cited in a past survey, were observed again, potentially affecting all 146 residents. The Administrator acknowledged the recurrence during an interview.
A facility failed to follow infection control procedures during perineal care, glucose monitoring, and medication cart management. A CNA did not perform hand hygiene or change gloves appropriately while caring for a resident, and a RN improperly disposed of a used lancet. Additionally, a personal drink was found on a medication cart among resident items.
A visitor entered the facility without proper identification when a surveyor was allowed entry through the main entrance without being greeted or identified by staff. The surveyor accessed the second floor without security measures, and interviews revealed that staff did not follow the protocol of verifying visitors via an I-Pad camera. The Administrator acknowledged the lapse in protocol, indicating a failure in the facility's visitation policy during the night shift.
A facility failed to provide proper wound care for a resident with a Stage 3 pressure ulcer, as the wound care nurse did not establish a clean field or change gloves after removing a soiled dressing. The nurse continued to handle clean supplies and apply treatment with the same gloves, risking contamination. Additionally, used items were improperly returned to the treatment cart, contrary to infection control practices.
Failure to Monitor and Assess Medication Administration
Penalty
Summary
The facility failed to provide adequate monitoring and assessment for a resident, leading to a deficiency in quality of care. Specifically, the facility did not adhere to its own medication administration policy, which requires vital signs to be checked and verified before administering medications. For Resident #1, there was a failure to assess the accuracy of medication administration, as evidenced by the administration of a medication without verifying the resident's vital signs as per the prescriber's orders. The orders required that the medication be held if certain vital sign thresholds were not met, but the facility did not document the necessary vital sign checks before administering the medication. Additionally, the facility did not comply with the doctor's orders to obtain and document vital signs every shift for 72 hours, followed by a reassessment for continued monitoring. There were significant gaps in the documentation of vital signs, with no recorded measurements between certain times, indicating a lack of reassessment and monitoring as required. Interviews with staff revealed a lack of consistent understanding and execution of procedures for managing changes in a resident's condition, further contributing to the deficiency.
Plan Of Correction
How the corrective action will be accomplished for any resident affected by deficient practice: Resident #1 has been discharged from the facility. LPN D and LPN B and licensed nursing staff involved with Resident #1 care were educated regarding Medication Administration, following medication administration parameters, identifying any change in residents vital signs from baseline and it in timely manner, and identifying change conditions and notifying physicians with residents change of conditions. How we identified other residents/areas that could potentially be affected and what corrective action will be taken: All residents on medications have potential to be by this practice. An audit of all current residents with medications with parameters including was completed to ensure medications are administered in accordance with the prescribers orders and parameters are followed through as per MD order. Any findings were addressed accordingly. Measures put in place or systemic changes made to ensure that the deficient practice will not recur: The facility's Medication Administration policy was reviewed by DON and no revision was required. Licensed Nursing staff were educated regarding Medication Administration, following medication administration parameters, identifying any change in residents vital signs from baseline and it in timely manner, and identifying change conditions and notifying physicians with residents change of conditions to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Medication administration competency on following parameters will be conducted with the license nurses. Unit Managers/Supervisors will monitor clinical alerts including, vital signs during the morning meeting and the end of each shift and any abnormality will be reported to MD for immediate interventions. How the corrective actions will be monitored and what quality assurance will be put in place title of person responsible for monitoring: The DON/Designee will audit randomly 10 residents on medications with parameters including weekly x4 then monthly x 3 to ensure that the parameters as ordered is being followed and MD notify as indicated. The results of all audits will be reported to QAPI committee for review and feedback on a monthly basis for the duration of audit until compliance achieved. Responsible party: DON
Failure to Ensure Adequate Hydration and Nutrition
Penalty
Summary
The facility failed to ensure adequate hydration and nutrition for one of the sampled residents. The resident, who was noted to have good mental cognition, was identified as lactose intolerant, and the medical doctor was informed by the registered dietitian to change the resident's supplement to Ensure Clear. However, there was a lack of documentation and monitoring of the resident's fluid intake by the nursing staff, specifically by Staff D, LPN, who did not record progress notes regarding the resident's fluid intake. Additionally, the multidisciplinary team did not conduct a nutritional evaluation related to the resident's medications. The nursing care plan for the resident did not include a focus on fluid and nutrition maintenance or any interventions to maintain the resident's fluid and nutrition status. Interviews with staff revealed a lack of recollection regarding monitoring the resident's fluid status, and the resident's physician indicated that he did not see a need for fluid orders until a later date, despite the resident's condition. This lack of coordinated care and documentation contributed to the deficiency in maintaining the resident's nutritional and hydration status.
Plan Of Correction
How the corrective action will be accomplished for any resident affected by deficient practice: Resident #1 no longer resides at the facility. The facility completed a review of the resident #1 clinical record for any opportunity of improvement in facility clinical services. RD# 1 no longer works at the facility. Staff G. RD#2 was educated on the Facility's policy, titled Resident Hydration and Prevention of and to monitor and assess residents with nutritional risk including risk for evaluation related to receiving medications such as medications and. Facility has hired a second RD that was educated on the Facility's policy, titled Resident Hydration and Prevention of to ensure monitor and assess residents with nutritional risk including risk for evaluation related to receiving medications such as medications and. Staff A, LPN and Staff D, LPN were educated on monitoring residents' fluid intake as per MD order and documenting in medical order, medical records and monitoring CNA task were reviewed to ensure include fluid intake. Resident #1 physician is no longer employed at the facility. How we identified other residents/areas that could potentially be affected and what corrective action will be taken: All residents on medications have potential to be affected by this practice. An audit of residents on medication was conducted to ensure their hydration status and electrolyte balance are monitored. All residents on were audited to ensure they have recent laboratory values that show a balance electrolyte panel. Care plans were updated accordingly, and interventions were implemented where necessary to ensure adequate hydration and nutrition. Any findings were addressed immediately. No additional adverse outcomes were identified audit of all current. Measures put in place or systemic changes made to ensure that the deficient practice will not recur: The facility's policy, titled Resident Hydration and Prevention of was reviewed by Director of Nursing and Registered Dietitian and no revision was required. Facility Registered Dietitians, Licensed nursing staff, and IDT team were educated on the above policies and education include: Fluid Intake monitoring protocols and reinforced among staff. Recognition of nutritional/hydration risks, especially related to medications such as. Residents at risk of nutritional/hydration status will be evaluated on a routine basis during the facility risk weekly meeting. Unit Managers/Supervisors will monitor clinical alerts including poor intake during the morning meeting and the end of each shift and any abnormality will be reported to MD and Registered Dietitian for immediate interventions. Registered Dietitian will evaluate residents with nutritional/hydration risks on a monthly basis and as needed as per clinical alerts to ensure their nutritional/hydration needs have been addressed. How the corrective actions will be monitored and what quality assurance will be put in place title of person responsible for monitoring: The Director of Nursing or designee will audit 10 residents with nutritional/hydration risks weekly x 4 then monthly x3 to evaluate that they have an individualized plan of care in place as well as to ensure they maintain a proper hydration status and electrolyte balance. The results of all audits will be reported to QAPI committee for review and feedback on a monthly basis for the duration of audit until compliance achieved. Responsible party: DON
Failure to Monitor and Assess Medication Administration
Penalty
Summary
The facility failed to provide adequate monitoring and assessment of medication administration for a resident, leading to a deficiency in care. The facility's policy on medication administration requires that medications be administered according to prescriber's orders, including checking and verifying vital signs before administration. However, for one resident, the facility did not adhere to these guidelines. The resident had specific orders to have vital signs obtained and documented every shift for 72 hours, followed by reassessment for continued monitoring. Despite this, there were gaps in the documentation of vital signs, indicating that the required monitoring was not performed as ordered. The resident, who had a good mental cognition score, was prescribed a medication with instructions to hold if certain vital sign thresholds were not met. On one occasion, the medication was administered without the necessary reassessment of vital signs, as there was no documentation between specific times on consecutive days. Interviews with staff revealed a lack of consistent understanding and execution of procedures for managing changes in a resident's condition, including when to notify a doctor or reassess vital signs. This lack of adherence to established protocols and documentation requirements contributed to the deficiency in providing adequate and appropriate health care to the resident.
Plan Of Correction
How the corrective action will be accomplished for any resident affected by deficient practice: Resident #1 has been discharged from the facility. LPN D and LPN B and licensed nursing staff involved with Resident #1 care were educated regarding Medication Administration, following medication administration parameters, identifying any change in residents vital signs from baseline and it in timely manner, and identifying change conditions and notifying physicians with residents change of conditions. How we identified other residents/areas that could potentially be affected and what corrective action will be taken: All residents on medications have potential to be by this practice. An audit of all current residents with medications with parameters including completed to ensure medications are administered in accordance with the prescribers orders and parameters are followed through as per MD order. Any findings were addressed accordingly. Measures put in place or systemic changes made to ensure that the deficient practice will not recur: The facility's Medication Administration policy was reviewed by DON and no revision was required. Licensed Nursing staff were educated regarding Medication Administration, following medication administration parameters, identifying any change in residents vital signs from baseline and it in timely manner, and identifying change conditions and notifying physicians with residents change of conditions to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Medication administration competency on following parameters will be conducted with the license nurses. Unit Managers/Supervisors will monitor clinical alerts including vital signs during the morning meeting and the end of each shift and any abnormality will be reported to MD for immediate interventions. How the corrective actions will be monitored and what quality assurance will be put in place title of person responsible for monitoring: The DON/Designee will audit randomly 10 residents on medications with parameters including weekly x4 then monthly x 3 to ensure that the parameters as ordered is being followed and MD notify as indicated. The results of all audits will be reported to QAPI committee for review and feedback on a monthly basis for the duration of audit until compliance achieved. Responsible party: DON
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to food safety standards during food preparation and handling, as observed during a series of inspections. Initially, a leak was noted at the filter from the steamer, which the Certified Dietary Manager (CDM) acknowledged and stated that Maintenance would address. Additionally, a dietary aide was observed using improper hand hygiene practices by rinsing gloved hands in a food preparation sink before handling ready-to-eat lettuce. The aide was instructed to remove the gloves and perform proper hand hygiene. Further observations revealed additional deficiencies. The dietary aide was seen stacking bowls with bare hands, directly touching the food contact surfaces, which required the bowls to be rewashed and sanitized. Moreover, the internal temperatures of pork roasts intended for a meal were found to be significantly below safe levels, indicating improper cooling after cooking. The CDM confirmed that the roasts were not cooled properly. The dietary aide was also observed washing gloved hands at a hand sink, which was not appropriate, and was again instructed to remove the gloves and perform hand hygiene. The CDM acknowledged these findings at the conclusion of the inspection.
Deficiency in Menu Planning and Nutritional Standards
Penalty
Summary
The facility failed to adhere to its Menu Planning policy, which is designed to meet the nutritional needs of residents in accordance with established national standards. During one week of the Spring Summer Menu 2024 cycle, the facility did not provide the required daily servings of fruit as outlined in their guidelines. Specifically, the menu was supposed to provide 2 to 2.5 cups of fruit per day, but the actual servings fell short, with some days offering only 1/2 cup of fruit. This discrepancy was observed over a week, affecting the nutritional intake of all residents consuming meals prepared by the facility. Interviews with the Registered Dietitian, Staff C, revealed that the menus were created and reviewed by the Corporate Dietitian. Staff C acknowledged that the facility's menus did not meet the required fruit servings as per the national standards. Although fruit servings could be provided upon request from residents, the standard menu did not fulfill the dietary guidelines. This oversight in menu planning and execution had the potential to impact the nutritional well-being of the residents.
Deficiencies in Resident Care and Accessibility
Penalty
Summary
The facility failed to ensure access to call devices for two residents, leading to significant issues in their care. One resident, with a cognitive response, was observed with the call bell on the floor and out of reach, resulting in her being unable to request assistance for a soiled adult incontinent brief. Another resident, with severe cognitive impairment, was found with the call bell device inaccessible, requiring intervention from the Director of Nursing and the Director of Maintenance to make it reachable. The facility also failed to ensure the proper functioning of air mattresses for two residents. Despite documentation indicating that the mattresses were checked every shift, observations revealed that the mattresses were not plugged in and therefore not functioning. This oversight was only discovered during a side-by-side observation with a Licensed Practical Nurse, who admitted to not noticing the issue until that moment. Additionally, the facility did not provide adequate access to wall lights for several residents, with pull cords being too short or inaccessible. This issue was compounded by the placement of privacy curtains obstructing access to shared wall lights. Furthermore, one resident was unable to access the bathroom due to obstructions and was without paper towels for several days, while another resident was left with an unmade bed for several hours despite requests for clean linens.
Deficiencies in Care Planning and Medication Monitoring
Penalty
Summary
The facility failed to develop comprehensive care plans for residents diagnosed with Post-Traumatic Stress Disorder (PTSD). Two residents, both with PTSD diagnoses, did not have care plans addressing their condition. One resident was admitted with PTSD, but the social services staff did not create a care plan, citing the resident's initial denial of anxiety and depression and the need to build rapport. Another resident was diagnosed with PTSD after admission, and although a stress for life screening was conducted, a care plan was only created after the surveyor's inquiry. The facility also failed to implement care plan interventions for residents on psychotropic medications. Two residents on such medications did not have their side effects monitored as required. One resident was prescribed Alprazolam for anxiety, but there was no order to monitor its side effects, despite pharmacy recommendations. The care plan for this resident included monitoring for side effects, but there was no evidence of implementation. Another resident on antidepressants also lacked monitoring for potential side effects, as indicated by the physician's orders and medication administration records. Interviews with facility staff revealed gaps in the care planning process and a lack of adherence to policies. The MDS Coordinator and Social Service Director acknowledged the absence of care plans for PTSD and the need for monitoring psychotropic medication side effects. The facility's policy requires comprehensive, person-centered care plans to be developed within specific timeframes, but these were not followed, leading to deficiencies in resident care.
Failure to Secure Sharps and Hazardous Items
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by several observations of unsecured sharps and hazardous items. One emergency cart was found unlocked and unattended, containing safety razors, scissors, and a box of lancets. Additionally, a medication cart was observed with a broken sharps disposal container, leaving sharps unsecured. These observations were confirmed by staff members present at the time, who acknowledged the issues but did not take immediate corrective action. Two residents were found with sharps in their rooms, posing potential safety risks. Resident #88, who has a cognitive score indicating full cognitive function, was observed with a safety razor in a Styrofoam cup on his nightstand. Resident #108, who has moderate cognitive impairment and Parkinson's disease, was seen using regular scissors to cut paper towels. The facility's care plan for Resident #108 did not include an assessment for scissors safety, and staff were unaware of the presence of scissors in her room until it was brought to their attention. Interviews with staff revealed a lack of awareness and adherence to safety protocols regarding sharps and hazardous items. The Director of Nursing and other staff members were not aware of the presence of these items in residents' rooms, and there was no immediate action taken to secure the environment. The facility's policy on sharps disposal was not effectively implemented, as evidenced by the unsecured sharps and the lack of a comprehensive policy addressing accident hazards.
Failure to Maintain Catheter Care and Dignity
Penalty
Summary
The facility failed to maintain the drainage bag for a resident with an indwelling urinary catheter in a manner that prevents infection and maintains dignity. The facility's policy on catheter care, revised in August 2022, specifies that catheter tubing and drainage bags should be kept off the floor to prevent urinary catheter-associated complications, including infections. However, observations revealed that the drainage bag for a resident with paraplegia and neuromuscular dysfunction of the bladder was found lying on the floor without a privacy cover on multiple occasions. This is contrary to the physician's orders and the resident's care plan, which emphasized keeping the drainage bag below the bladder level, checking placement and function every shift, and ensuring the bag is covered for privacy. The resident, who was cognitively intact with a Brief Interview of Mental Status score of 14, expressed that she was informed her catheter would be changed every six months, but she insisted on monthly changes. Despite the facility's policy and the resident's care plan, the observations indicated non-compliance with infection control and dignity protocols. A Certified Nursing Assistant confirmed that catheter care is documented daily, and the bag should be hanging with a privacy cover, yet these practices were not consistently followed for the resident in question.
Failure to Monitor Nutritional Supplement Intake
Penalty
Summary
The facility failed to adequately monitor the intake of nutritional supplements for two residents, leading to significant weight loss and potential health risks. Resident #52, who had multiple health conditions including heart failure, renal insufficiency, and malnutrition, was dependent on staff for eating and required nutritional supplements as part of their care plan. Despite being on a regular diet with puree texture and nectar thickened liquids, the resident experienced a significant weight loss of 13.01% over a short period. Interviews with staff revealed a lack of documentation regarding the resident's intake of supplements, and discrepancies in weight measurements were noted without proper follow-up or verification. Resident #98, diagnosed with complex regional pain syndrome and obstructive uropathy, also experienced severe weight loss over several months. The resident's dietary plan included nutritional supplements like Magic Cup and Ensure Plus, but there was a lack of documentation and monitoring of the intake of these supplements. Observations showed that the resident was not provided with the recommended fortified foods, and staff failed to ensure the resident received the correct nutritional supplements during meals. Interviews with staff indicated a lack of awareness and understanding of the nutritional supplements, further contributing to the deficiency. The facility's failure to document and monitor the intake of nutritional supplements for these residents highlights a significant deficiency in the care provided. The lack of proper documentation and staff awareness led to inadequate nutritional support for residents at high risk of malnutrition and weight loss. This deficiency was identified through observations, interviews, and record reviews, revealing a systemic issue in the facility's approach to managing residents' nutritional needs.
Deficiencies in Respiratory Care and Infection Control
Penalty
Summary
The facility failed to ensure that a resident receiving oxygen had a physician's order, affecting one of the four sampled residents reviewed for respiratory care. Specifically, Resident #111 was observed wearing oxygen without any evidence of a physician's order for oxygen administration. This oversight was noted during an observation on December 2, 2024, when the resident was seen sitting up in bed with an oxygen concentrator set at 2 liters. The resident had been admitted with diagnoses including acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Additionally, the facility did not maintain respiratory supplies in a manner that prevents infection for four sampled residents. Resident #6's nebulizer mask was observed on top of a personal cart and later on a nightstand, not stored in a plastic bag as required. Resident #17's oxygen tubing had not been changed since November 11, 2024, despite a physician's order for weekly changes. Resident #8's oxygen cannula and tubing were observed with a date tag of November 18, 2024, and were found on the floor, not stored in any plastic containment. Interviews with the residents and the Director of Nursing (DON) revealed inconsistencies in the facility's adherence to infection control protocols. The DON confirmed that residents need a physician's order for oxygen and that oxygen tubing should be changed weekly. The DON also stated that nebulizer masks should be stored in plastic bags when not in use. These observations and interviews highlight the facility's failure to follow its own infection prevention policies related to respiratory care equipment.
Failure to Identify PTSD Triggers in Residents
Penalty
Summary
The facility failed to identify triggers for residents diagnosed with Post-Traumatic Stress Disorder (PTSD), specifically for two residents sampled for mood and behavior. The facility's policy on trauma-informed care emphasizes the importance of identifying and minimizing triggers for trauma survivors. However, the facility did not adhere to these guidelines, as evidenced by the lack of documentation and care planning for the residents' PTSD triggers. Resident #28 was admitted with diagnoses including PTSD and had a Brief Interview of Mental Status (BIMS) score indicating intact cognition. Despite this, there was no care plan addressing PTSD, and the resident expressed dissatisfaction with the facility's response to his needs. Interviews with staff revealed a lack of understanding and training regarding trauma-informed care, with staff unable to identify or address PTSD triggers effectively. The social services staff admitted to not having created a care plan for PTSD, citing a need to build rapport with the resident first, despite the resident's admission being several months prior. Similarly, Resident #72, who also had a diagnosis of PTSD, did not have documented triggers in their care plan. The social service director acknowledged that the stress for life screenings conducted did not address or ask about triggers, and there was no proactive approach to identifying them. The resident mentioned having triggers related to control and possession of items but was not able to articulate them clearly. The facility's failure to document and address these triggers indicates a deficiency in providing trauma-informed care as per their policy.
Controlled Substance Reconciliation Failures
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled substance medications for six residents, leading to discrepancies in medication administration records and controlled drug disposition sheets. For Resident #10, there was a mismatch between the documented administration of Percocet and the actual count of tablets, indicating potential errors in medication tracking. Similarly, Resident #51's records showed an undocumented administration of Oxycodone, which was not reflected in the controlled drug disposition sheet, highlighting a lack of proper reconciliation. Resident #73's records revealed inconsistencies in the documentation of Temazepam administration, with a missing entry on the disposition sheet despite the correct count of capsules. This suggests a failure in maintaining accurate records of medication administration. For Resident #88, the records showed discrepancies between the medication administration record and the controlled drug disposition sheet for Morphine Sulfate, indicating a lack of proper reconciliation and documentation. Residents #345 and #346 also experienced similar issues, with discrepancies between the medication administration records and the controlled drug disposition sheets for Tramadol and Oxycodone, respectively. These inconsistencies point to a systemic issue in the facility's process for reconciling controlled substances, as acknowledged by the Director of Nursing, who noted that the current plan in place was not effective in addressing these discrepancies.
Medication Administration Errors and Improper Insulin Pen Priming
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a rate of 12.50 percent. This deficiency affected two residents, one of whom was Resident #63. During a medication administration observation, it was noted that three medications scheduled for 9:00 AM were not administered during the med pass. Staff B, a Registered Nurse, documented that these medications were given, but later admitted that one of the medications, Ferrous Sulfate, was not available and had not been ordered. The Director of Nursing confirmed that these medications were omitted during the med pass. Another incident involved Resident #32, who was prescribed Fiasp FlexTouch insulin for diabetes management. During a med pass, Staff B was observed priming the insulin pen incorrectly by holding it upside down, contrary to the manufacturer's instructions. This improper technique could potentially affect the accuracy of the insulin dosage. Staff B stated she was shown this method by another nurse, indicating a possible gap in training or adherence to proper procedures. These observations highlight significant lapses in medication administration practices, including failure to administer prescribed medications and incorrect priming of an insulin pen. These errors were identified through direct observation and interviews with staff, revealing issues with both medication availability and staff training or adherence to protocols.
Medication Security and Disposal Deficiencies
Penalty
Summary
The facility failed to secure medications properly, as evidenced by several observations and interviews. Medications were found unsecured at the bedside for three residents, and a medication cart was left unlocked and unattended. Specifically, a Registered Nurse left an insulin pen on top of an unlocked and unattended medication cart. Additionally, a resident with severe cognitive impairment was found with a bottle of Tums on her nightstand without an evaluation for self-administration of medication. Another resident, who had intact cognition, had two bottles of artificial tears on her overbed table without documentation of administration or evaluation for self-administration. The facility also failed to properly dispose of medications during medication observations. A Licensed Practical Nurse disposed of a pill in a sharps container instead of using the drug buster solution as per facility policy. Another incident involved a Registered Nurse improperly discarding spilled Senna Plus tablets into a sharps container, despite being advised by a wound care nurse to use the drug buster located in the medication room. The Director of Nursing acknowledged that discarding medications in the sharps container was a bad habit among the nurses. Furthermore, a resident with moderate cognitive impairment was found with over-the-counter medications on her nightstand, including expired nasal spray, without any orders for self-administration. The Director of Nursing admitted that residents' families often bring in medications, complicating efforts to keep medications out of residents' rooms. Despite recent inspections, the facility continued to struggle with ensuring medications were not left unsecured in residents' rooms.
Failure to Meet Residents' Dietary Preferences and Needs
Penalty
Summary
The facility failed to provide meals that met the dietary preferences, allergies, and intolerances of six residents during dining observations. Resident #122, who has slight cognitive impairment, reported not receiving the grits listed on her meal ticket and was unable to get a turkey sandwich as requested. Resident #54, with a diagnosis of hemiplegia, received a meal tray that did not match the no added salt diet specified on her meal ticket, missing apple juice and ginger ale. Resident #39, who has intact cognition, received a meal tray missing a fruit cup and diet ginger ale, contrary to the regular diet specified on the meal ticket. Resident #69, with moderate cognitive impairment, received a meal tray missing sugar-free lemonade and ice cream, as noted by her private aid who frequently observed discrepancies between meal tickets and trays. Resident #44, with moderate cognitive impairment, received a meal tray missing crackers, mandarin oranges, and diet ginger ale, which were specified on her no added salt diet meal ticket. Resident #46, who is cognitively intact, did not receive a banana listed on the breakfast meal ticket, with grapes substituted instead. The Food Service Assistant, who had been working at the facility for a short period, acknowledged the absence of documented preferences for Resident #46 in the meal tracker system. The facility's process for ensuring meal accuracy, involving a starter and checker, was not effectively implemented, leading to these deficiencies.
Failure to Provide Adaptive Eating Equipment to Resident
Penalty
Summary
The facility failed to provide necessary adaptive eating equipment to a resident, identified as Resident #46, who required such equipment due to medical conditions including paraplegia and neuromuscular dysfunction of the bladder. The resident had a physician's order for a plate guard, spill-proof cup with two handles, and weighted utensils for all meals. However, observations revealed that the resident did not receive the appropriate equipment during meals. On one occasion, the resident's water and cups were out of reach, and on another, the breakfast tray included a one-handled cup without a spill lid and a two-handled cup with a loose lid, contrary to the prescribed adaptive equipment. Interviews with staff members, including a CNA, a Food Service Assistant, and the Director of Rehab, confirmed the oversight. The CNA acknowledged the improper use of cups and lids, while the Food Service Assistant admitted that the resident did not receive the correct adaptive equipment. The Director of Rehab confirmed the resident's need for adaptive equipment due to tremors and the necessity for stability and spill prevention. The facility's policy on adaptive equipment was not adhered to, resulting in the resident not receiving the required assistance to safely consume meals.
Repeated Deficiencies in Pharmacy Services and Assistive Devices
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to effectively implement corrective actions for identified quality deficiencies. This was evidenced by repeated deficient practices in pharmacy services and assistive devices, specifically related to F755 and F810. These deficiencies were previously cited during a recertification survey with an exit date of 08/24/23 and were observed again during the current survey. The repeated deficiencies have the potential to affect all 146 residents residing in the facility at the time of the survey. During an interview, the facility's Administrator acknowledged the recurrence of these deficiencies.
Infection Control Deficiencies in Resident Care and Equipment Handling
Penalty
Summary
The facility failed to adhere to standard infection control procedures during perineal care for a resident with intact cognition and multiple diagnoses, including Type 2 Diabetes Mellitus and Dysphagia following Cerebral Infarction. During the observation, a CNA did not perform hand hygiene after glove removal and before donning a new set of gloves. The CNA also failed to change gloves between different tasks, such as washing the resident's perineal area and then touching other parts of the resident's body and bed controls. Additionally, the CNA used the same water to wash different areas of the resident's body, including the back anal region and upper back, without changing gloves or performing hand hygiene. The facility also failed to properly dispose of contaminated lancets used for glucose monitoring. A RN encapsulated a used lancet in a glove and disposed of it in an open trash container next to a resident's bed, believing it was safe because the needle retracted. Furthermore, a personal drink was observed on a medication cart among items used for residents, which was acknowledged by the staff member as inappropriate. These actions demonstrate a lack of adherence to infection control protocols, potentially compromising resident safety.
Visitor Entry Without Proper Identification
Penalty
Summary
The facility failed to provide a safe environment for its residents by allowing a visitor to enter the premises without proper identification. On the morning of June 25, 2024, a surveyor was able to enter the facility at 6:14 AM through the main entrance after ringing the doorbell, which automatically opened the door. The surveyor proceeded to the reception desk and completed the registration process without being greeted or identified by any staff member. The surveyor then accessed the second floor, where the long-term care units are located, without encountering any security measures such as an elevator code. Interviews with various staff members revealed that none of them had opened the door for the surveyor, and there was no designated supervisor during the night shift. Staff members indicated that the facility's protocol involved checking an I-Pad camera at the nurse's station to identify visitors before granting entry. However, this protocol was not followed, as no staff member verified the surveyor's identity or purpose of visit. The facility's Administrator acknowledged the lapse in protocol and stated that the staff should have come to the door to identify the surveyor, highlighting a failure in the facility's visitation policy and security measures during the night shift.
Failure to Adhere to Wound Care Protocols
Penalty
Summary
The facility failed to provide wound care consistent with professional standards for a resident with severe cognitive impairment and multiple medical conditions, including quadriplegia and diabetes. The resident had a Stage 3 pressure ulcer on the right buttock, acquired while in the facility, which required specific wound care treatment. During an observation, the wound care nurse (WCN) did not establish a clean field for the wound care supplies and failed to change gloves after removing the soiled dressing, which is against the facility's wound care policy. The WCN continued to handle clean supplies and apply treatment to the wound with the same soiled gloves, increasing the risk of contamination. Additionally, the WCN placed the soiled dressing on the bed pad underneath the resident and later retrieved it with the same gloves. The WCN also placed used items, such as a Medihoney tube and scissors, back into the treatment cart after using them in the resident's room, which the Assistant Director of Nursing (ADON) confirmed should not occur due to infection risk. These actions demonstrate a failure to adhere to proper infection control practices during wound care, as outlined in the facility's policy.
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What surveyors actually found near you
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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 Boca Raton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Boca Circle Rehabilitation Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Legacy At Boca Raton Rehabilitation And Nursing Ce | 1 mi | ★★★★★ | 0 | 0 |
| Willowbrooke Court At St Andrews Estates | 1.5 mi | ★★★★★ | 0 | 0 |
| Willowbrooke Court Skilled Care Center - Edgewater | 1.7 mi | ★★★★★ | 0 | 0 |
| Stratford Court Of Boca Raton | 1.8 mi | ★★★★★ | 10 | 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.