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 Glades Health Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that the facility did not perform and/or could not document the required annual 90‑minute test of battery-powered emergency lighting as required by NFPA 101 (2012 and 2021). During a record review with the Maintenance Director, no records were available to show that the annual 90‑minute emergency lighting test had been completed, and the Maintenance Director acknowledged the absence of this documentation, resulting in a cited deficiency affecting all occupants of the building.
Surveyors found that the facility failed to maintain required fire alarm system documentation and testing records. During record review with the Maintenance Director, there was no vendor-signed log book at the fire panel documenting work performed at each visit, no documentation of biennial smoke detector sensitivity testing, and no fire alarm system design plans located at the fire panel, as required by NFPA 101 and NFPA 72.
Surveyors found that the facility failed to maintain required documentation for multiple fire protection system tests and inspections, including the annual fire hydrant flow test, the five-year GPM test of the hydrant, the five-year internal inspection of the fire riser, and the five-year hydrostatic test of the FDC, as required by NFPA 101 and NFPA 25. In addition, the facility lacked records of required fire drills for each shift per quarter, with missing drills for one quarter’s third shift and for the second and third shifts of the last quarter of the prior year. The Maintenance Director acknowledged that these records were not available.
Surveyors found that the facility did not comply with NFPA 101 fire drill requirements when record review with the Maintenance Director showed missing documentation of quarterly fire drills for the third shift in one quarter and for the second and third shifts in another quarter. Required drills, which must simulate emergency fire conditions and include fire alarm activation or coded announcements at night, were not documented as completed for these periods. The Maintenance Director acknowledged the absence of records, and the deficiency was cited under NFPA 2021 19.7.1 as a Class III violation affecting all occupants.
Surveyors found that the facility did not perform or could not document required annual testing of electrical receptacles for tension and polarity in patient care areas, as mandated by NFPA 99. During record review with the Maintenance Director, no evidence was produced to show that hospital‑grade and other required receptacles had been tested at the specified intervals, and the Maintenance Director acknowledged this lack of documentation. This noncompliance with NFPA 99 Section 6.3.4 was cited as a deficiency affecting all occupants who rely on the facility’s electrical systems.
Surveyors found that the facility did not have documentation showing that the essential electrical system’s main and feeder circuit breakers were exercised annually in accordance with manufacturer recommendations and NFPA 99 requirements. During record review with the Maintenance Director, no records could be produced to verify that these breakers had been properly exercised, and the Maintenance Director acknowledged this failure. This deficiency was cited as affecting all occupants due to noncompliance with required essential electrical system maintenance and testing standards.
Surveyors found that the facility did not maintain required documentation showing that annual NFPA 99-compliant testing (including physical integrity, resistance, leakage current, and touch current tests) was performed on electrical equipment used for patient care. During record review with the Maintenance Director, no records could be produced to verify that this testing had been completed as required, and the Maintenance Director acknowledged the lack of documentation.
Surveyors observed that more than 12 "E" oxygen cylinders (18 total) were stored in a sprinkler room within five feet of combustible materials, contrary to NFPA 99 requirements for gas equipment cylinder storage. The Maintenance Director confirmed this storage practice during the survey. This noncompliance with NFPA 99 sections 11.3.1–11.3.3 was cited as a deficiency affecting all occupants in the event of a fire or other emergency.
Surveyors found that the facility failed to maintain its sprinkler system’s fire riser in proper working order, as evidenced by multiple red tags from the sprinkler vendor and lack of supporting documentation. When the system was not fully functional, the facility did not notify the Agency for Health Care Administration or local fire rescue as required, and did not initiate a fire watch. The Maintenance Director and the Administrator acknowledged that these notifications and the fire watch were not carried out, creating a deficiency that could affect all occupants during a fire or other emergency.
Surveyors found that the facility installed a 250 KW generator outside directly in front of four rooms, including room 30, without submitting required construction plans to the Agency’s Office of Plans and Construction as mandated by FAC 59A-4.134 and the Florida Building Code. During record review with the Maintenance Director and the Administrator, the facility could not provide documentation that these rooms would never be used as patient rooms, despite the generator’s location. The facility leadership acknowledged the lack of required documentation and failure to obtain prior written approval, a deficiency that the surveyors noted could affect all occupants in the event of a fire or other emergency.
Surveyors found that the facility did not comply with FAC 59A-4.126 requiring semiannual testing of its emergency management plan. During record review with the Maintenance Director and the Administrator, the facility was unable to produce documentation that the emergency management plan had been tested as required, either through actual events or planned drills. Both the Maintenance Director and the Administrator acknowledged the absence of documentation, and the deficiency was cited as a Class III violation with the potential to affect all occupants during a fire or other emergency.
Surveyors found that the facility did not comply with NFPA 99 (2021) requirements for security management because it lacked documentation showing that its Security Vulnerability Assessment (SVA) was updated and reviewed on an annual basis. During record review with the Maintenance Director and the Administrator, no current or yearly SVA documentation could be produced, and both leaders acknowledged that the assessment had not been updated and reviewed each year, resulting in a cited Class III deficiency affecting all occupants in the event of a fire or other emergency.
A facility failed to ensure proper oversight in nutritional assessments, as a CDM conducted quarterly assessments for a resident with multiple health issues without Dietitian review. The Dietitian was unaware of the need for oversight, leading to a deficiency affecting the resident and potentially impacting others.
The facility did not follow the approved menu during a lunch service, substituting chicken and green beans for the planned BBQ ribs and corn on the cob. Residents with pork dislikes were affected, as they were not informed of the alternate meal options. The kitchen manager confirmed the oversight and acknowledged the absence of planned vegetables.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling medical devices, affecting multiple residents. Observations revealed a lack of EBP measures, such as signage and PPE kits, and staff did not adhere to hand hygiene protocols during care. Interviews indicated a lack of staff awareness and understanding of EBP and PPE requirements, contributing to the deficiency.
The facility failed to ensure accurate MDS assessments for three residents, leading to deficiencies in care. A resident with dementia was inaccurately assessed as having no upper extremity impairment, despite needing a hand splint. Another resident was recorded as having adequate hearing, despite severe hearing loss and lack of hearing aids. Additionally, a resident on anti-platelet medication had no documentation of this in the MDS, despite its confirmed administration.
The facility failed to develop comprehensive care plans for two residents. One resident with severe cognitive impairment experienced a fall resulting in a thumb dislocation, but the care plan was not updated to address the injury or splint care. Another resident was observed using bed side rails, but this was not documented in the care plan. The MDS Coordinator acknowledged these deficiencies.
A resident with severe cognitive impairment and an indwelling urinary catheter did not receive proper personal care from a CNA, who failed to perform hand hygiene before donning gloves and did not provide necessary peri-care. The resident's care plan noted potential complications from catheter use, and the resident was colonized with E. Coli, indicating improper catheter care.
The facility failed to ensure that fried fish was cooked to a safe temperature for a resident. The fish was initially fried and placed on the steam table without checking its temperature, which was later found to be 125 degrees F, below the required 145 degrees F. After further cooking, the temperature reached 164 degrees F. The Kitchen Manager acknowledged the failure to properly check and maintain the safe temperature.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Failure to Perform and Document Annual 90‑Minute Emergency Battery Lighting Test
Penalty
Summary
The deficiency involves the facility’s failure to perform and document required annual 90‑minute testing of battery-powered emergency lighting in accordance with NFPA 101 (2012 and 2021 editions), Sections 18.2.9.1 and 19.2.9.1. During a record review conducted between 9:15 AM and 1:30 PM with the Maintenance Director, surveyors were unable to locate documentation showing that the annual 90‑minute emergency battery lighting test had been completed. The Maintenance Director acknowledged that the facility could not provide documentation that this required annual 90‑minute testing of the battery lighting was performed. The deficiency was cited as affecting all occupants of the building under NFPA 101 2012 and 2021, 19.2.9.1, Class III. No specific residents, medical histories, or clinical conditions were mentioned in the report, and the findings were limited to the facility’s emergency lighting testing and documentation practices as observed during the surveyor’s record review and staff interview.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. The 90 minute battery lighting test was completed and documentation is placed in the maintenance director book. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for three months random checks of completed documentation. Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. The 90 minute battery lighting test was completed and documentation is placed in the maintenance director book The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Failure to Maintain Required Fire Alarm Documentation and Testing Records
Penalty
Summary
Surveyors identified deficiencies related to the facility’s fire alarm system testing and maintenance during record review with the Maintenance Director between 9:15 AM and 1:30 PM. The facility did not have a log book located at the fire alarm panel that was signed by the fire alarm vendor and documented the work completed at each visit, as required by NFPA 101 and NFPA 72. The Maintenance Director acknowledged that the facility failed to provide this log book at the fire panel. Additionally, the facility was unable to provide documentation that biennial smoke detector sensitivity testing had been performed, and the Maintenance Director confirmed that this documentation was not available. Surveyors also found that the fire alarm system design plans were not located at the fire panel as required. The Maintenance Director acknowledged that the facility failed to provide the fire alarm system design plans at the fire panel. These findings were cited under NFPA 101 2021 sections 9.6.5 and 9.6.7 and NFPA 72.
Plan Of Correction
The fire alarm book was placed at the fire panel with the pull station zones and building map. (Fire Alarm System Design Plan) This was completed on [R] The biennial sensitivity testing on the smoke detectors was completed on [R] The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation. The fire alarm book was placed at the fire panel with the pull station zones and building map. (Fire Alarm System Design Plan) This was completed on The biennial sensitivity testing on the smoke detectors was completed on The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation,
Failure to Maintain Sprinkler System Testing and Fire Drill Documentation
Penalty
Summary
Surveyors identified deficiencies related to the facility’s failure to maintain and test its automatic sprinkler and associated fire protection systems in accordance with NFPA 101 and NFPA 25. During record review between 9:15 AM and 1:30 PM with the Maintenance Director, the facility was unable to provide documentation that an annual flow test had been performed on the on-site fire hydrant as required. The Maintenance Director acknowledged that the facility failed to provide documentation that this annual hydrant flow test was completed. Further record review during the same time period showed that the facility also lacked documentation of the required five-year gallons-per-minute (GPM) testing of the fire hydrant. In addition, the facility could not produce records showing that a five-year internal inspection of the fire riser had been performed. The Maintenance Director acknowledged the absence of documentation for the five-year internal riser inspection. Surveyors also found that the facility failed to provide documentation that a five-year hydrostatic test of the Fire Department Connection (FDC) had been completed. Separately, the surveyors reviewed fire drill records and determined that the facility did not have documentation of required fire drills for each shift per quarter. Specifically, fire drills were missing for the third shift of the first quarter of one year and for the second and third shifts of the last quarter of the prior year. The Maintenance Director acknowledged that the facility failed to provide documentation that these fire drills were performed.
Plan Of Correction
The five year gallon per minute testing was completed on [R] The five year internal inspection was performed on the riser on [R] The five year hydrostatic testing was performed and completed on [R] The five year gallon per minute testing on the fire hydrant was completed on [R] The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation. The five year gallon per minute testing was completed on [R] The five year internal inspection was performed on the riser on [R] The five year hydrostatic testing was performed and completed on [R] The five year gallon per minute testing on the fire hydrant was completed on [R] The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation.
Failure to Conduct and Document Required Quarterly Fire Drills on All Shifts
Penalty
Summary
Surveyors identified a deficiency related to fire drill compliance and documentation under NFPA 101 (2021). During record review conducted between 9:15 AM and 1:30 PM with the Maintenance Director, the facility was unable to provide documentation that required fire drills had been performed. Specifically, fire drills were missing for the first quarter of 2026 on the third shift, as well as for the second and third shifts of the last quarter of 2025. The cited regulations require that fire drills in health care occupancies simulate emergency fire conditions, include activation of the fire alarm system notification appliances (with limited exceptions for nighttime coded announcements), and be conducted at least quarterly on each shift. The survey findings noted that these missing drills and lack of documentation represented a failure to comply with NFPA 101 2021, Section 19.7.1, which mandates quarterly fire drills on each shift to familiarize personnel with emergency signals and required actions. The Maintenance Director acknowledged that the facility failed to provide documentation that the fire drills were performed for the identified quarters and shifts. The deficiency was classified under NFPA 2021 19.7.1 as a Class III violation and was determined to have the potential to affect all occupants in the facility in the event of a fire or other emergency.
Plan Of Correction
Facility conducted fire drills on all three shifts. These drills were done on [R] , and [R] . The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation. Facility conducted fire drills on all three shifts. These drills were done on [R] , [R] , and [R] . The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation.
Failure to Perform and Document Required Annual Receptacle Testing
Penalty
Summary
The deficiency involves the facility’s failure to comply with NFPA 99 requirements for electrical systems maintenance and testing, specifically related to receptacle testing for tension and polarity. During a record review conducted between 9:15 AM and 1:30 PM with the Maintenance Director, surveyors requested documentation showing that hospital‑grade and other required receptacles at patient care locations had been tested at the required intervals. The facility was unable to provide documentation that annual testing for receptacle tension and polarity had been performed as required by NFPA 99 (referenced as both the 2012 and 2021 editions in the report). The Maintenance Director acknowledged that the facility failed to provide documentation demonstrating that the required annual receptacle testing for tension and polarity had been completed. The report notes that this failure to maintain and document testing of electrical receptacles could affect all occupants in the facility in the event of a fire or other emergency. No specific residents, clinical conditions, or individual patient events are described in the report; the deficiency is based solely on the absence of required testing records and the associated noncompliance with NFPA 99 Section 6.3.4 for Class III electrical systems.
Plan Of Correction
The Tension and Polarity test was performed throughout the building and completed on .The facility has determined that all residents have the potential to be affected.An in-service education program will be conducted by the administrator.The administrator will conduct for a period of three months a random audit of completed documentation. The Tension and Polarity test was performed throughout the building and completed on [R] . The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation.
Failure to Exercise and Document Main and Feeder Breaker Maintenance per NFPA 99
Penalty
Summary
The deficiency involves the facility’s failure to maintain and document required maintenance and testing of the essential electrical system’s main and feeder circuit breakers in accordance with NFPA 99 and manufacturer recommendations. During a record review conducted between 9:15 AM and 1:30 PM with the Maintenance Director, surveyors requested documentation showing that the main and feeder breakers had been exercised annually as required. The facility was unable to provide records demonstrating that these breakers were exercised per the manufacturer’s recommendations. The Maintenance Director acknowledged that the facility failed to provide documentation that the main and feeder breakers were exercised according to the manufacturer’s recommendations. This lack of documentation and evidence of required exercising of the breakers was cited as noncompliance with NFPA 99 (referencing sections 6.4.4, 6.5.4, 6.6.4/6.5.4 Class III) and related standards governing essential electrical system maintenance and testing. The deficiency was noted as having the potential to affect all occupants in the facility in the event of a fire or other emergency.
Plan Of Correction
A generator load test was performed on . Documentation of work performed is in the record book and print out from machine is also onThe facility has determined that all residents have the potential to be affected.An in-service education program will be conducted by the administrator.The administrator will conduct for a period of three months a random audit of completed documentation. K0918 A generator load test was performed on [R] Documentation of work performed is in the record book, and print out from machine is also on [R] The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation.
Failure to Maintain Annual Testing Documentation for Patient-Care Electrical Equipment
Penalty
Summary
The deficiency involves the facility’s failure to comply with NFPA 99 requirements for testing and maintenance of patient-care-related electrical equipment (PCREE). During a record review conducted between 9:15 AM and 1:30 PM with the Maintenance Director, surveyors requested documentation showing that physical integrity, resistance, leakage current, and touch current tests were performed on electrical equipment used for patient care. The facility was unable to provide documentation that this electrical testing was completed on an annual basis as required by NFPA 99. The Maintenance Director acknowledged that the facility failed to provide documentation demonstrating that annual electrical testing of equipment used for patient care had been completed. The deficiency was cited under NFPA 99 (referencing sections 10.3, 10.5.2.1, and 10.5.2.5, among others) and was noted as affecting all occupants in the facility in the event of a fire or other emergency. No specific residents, medical histories, or clinical conditions were described in the report.
Plan Of Correction
The testing of electrical equipment was performed by DESCO throughout the building. A report has been provided and work was completed on . The facility has determined that all residents have the potential to be affected An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation. The testing of electrical equipment was performed by DESCO throughout the building. A report has been provided and work was completed onThe facility has determined that all residents have the potential to be affected.An in-service education program will be conducted by the administrator.The administrator will conduct for a period of three months a random audit of completed documentation.
Improper Storage of Oxygen Cylinders Near Combustibles
Penalty
Summary
The deficiency involves improper storage of medical gas cylinders, specifically more than 12 "E" oxygen tanks, in violation of NFPA 99 requirements. During an observation at 4:30 PM with the Maintenance Director, surveyors noted that 18 "E" tanks were being stored in a sprinkler room. These cylinders were located within five feet of combustible materials, contrary to NFPA 99 (2012 and 2021 editions), which requires that oxidizing gas cylinders in quantities greater than 300 cubic feet be separated from combustibles by at least 20 feet (or 5 feet if the area is sprinklered) or stored in an appropriately rated noncombustible cabinet. The report states that the storage arrangement did not comply with NFPA 99 sections 11.3.1, 11.3.2, and 11.3.3, which govern gas equipment cylinder and container storage, including separation from combustibles. The Maintenance Director acknowledged during the survey that 18 "E" tanks were stored in the sprinkler room within five feet of combustibles. The deficiency is cited as affecting all occupants in the facility in the event of a fire or other emergency, and no additional resident-specific clinical details are provided in the report.
Plan Of Correction
tank cylinders were removed from certain locations and the number of tanks were reduced in those locations. The tanks were relocated to a locked designated area. This was completed on . [R] tank cylinders were removed from certain locations and the number of tanks were reduced in those locations. The tanks were relocated to a locked designated area. This was completed on [R] . The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation.
Failure to Maintain Sprinkler System and Implement Required Notifications and Fire Watch
Penalty
Summary
Surveyors identified a deficiency related to fire protection and life safety requirements under 59A-4.130 and NFPA 101. During record review between 9:15 AM and 1:30 PM with the Maintenance Director, the facility could not provide documentation that the fire riser and associated sprinkler system were maintained in proper working order. Three red tags from the sprinkler vendor were observed on the sprinkler system since 2025, indicating unresolved issues with the system’s status. The facility also failed to follow required procedures when the fire protection system was not fully functional. Specifically, the facility did not notify the authorities having jurisdiction, including the Agency for Health Care Administration and Palm Beach County Fire Rescue, as required when there is a system failure of the sprinkler system. In addition, the facility did not implement a fire watch during the period when the sprinkler system was not in proper working order. The Maintenance Director and the Administrator acknowledged these failures to notify the appropriate authorities and to initiate a fire watch. This deficiency had the potential to affect all occupants of the facility in the event of a fire or other emergency.
Plan Of Correction
The facility placed itself on a self imposed fire watch due to the red tags given to us from our sprinkler system vendor. The fire watch started on [R] and is still on-going pending the final report from our vendor. The facility notified the local area office of AHCA and the Fire Marshall of the Palm Beach Fire Rescue. The facility notified both parties on [R]. Daily logs are being sent to the AHCA surveyor and the fire Marshall. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct for a period of three months a random audit of completed documentation.
Failure to Submit Required Construction Plans Before Generator Installation
Penalty
Summary
The deficiency involves the facility’s failure to comply with Florida Administrative Code 59A-4.134 and the Florida Building Code requirements for plans submittal prior to construction work. Surveyors, during record review with the Maintenance Director and the Administrator between 9:15 AM and 1:30 PM, determined that the facility did not submit required plans to the Agency’s Office of Plans and Construction before installing a 250 KW generator outside the building. This generator was installed directly in front of four identified rooms, including room 30, without prior written approval or documented review by the Office of Plans and Construction as required for construction, additions, or modifications. During the review, the facility was unable to provide documentation that these four rooms, including room 30, would never be used as patient rooms, despite the generator’s placement directly in front of them. The Maintenance Director and the Administrator acknowledged that the facility failed to provide such documentation and that plans had not been submitted to the Office of Plans and Construction before the generator installation. The survey findings state that this failure to submit plans and obtain approval before the work could affect all occupants in the facility in case of a fire or other emergency.
Plan Of Correction
The following resident room numbers 24, 25, 28, and 30 have been decommissioned and have been taken out of service until the generator is relocated. The four rooms will remain out of service until the project is complete and deemed in compliance by AHCA. A submission for the relocation of the generator will be sent to the Office of Plans and Construction for a full plan review. This submission to the OPC will occur no later than . Upon approval of the project from OPC with an issued project number, the relocation of the generator will immediately be initiated. The facility has determined that all residents have the potential to be affected. An in-service education will be conducted by the administrator. The administrator will conduct a three month review of all necessary paperwork for relocation paperwork.
Failure to Conduct and Document Semiannual Emergency Management Plan Testing
Penalty
Summary
The facility failed to comply with Florida Administrative Code 59A-4.126, which requires a written, comprehensive emergency management plan to be tested semiannually, either in response to an actual disaster/emergency or through a planned drill. During record review between 9:15 AM and 1:30 PM with the Maintenance Director and the Administrator, surveyors requested documentation of the semiannual testing of the emergency management plan. The facility was unable to provide any documentation showing that these required semiannual tests had been performed. The Maintenance Director and the Administrator acknowledged that the facility failed to provide documentation that the semiannual testing of the emergency management plan was performed. This deficiency was cited as a Class III violation and was noted as having the potential to affect all occupants in the facility in case of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report, and the deficiency centered solely on the lack of documented semiannual testing of the emergency management plan.
Plan Of Correction
The facility ran in-service drill for internal and external drills. Paperwork is in the log book in the maintenance director's books. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted. The administrator will conduct a three month check to verify completion of documentation.
Failure to Annually Update and Review Security Vulnerability Assessment
Penalty
Summary
The facility failed to comply with NFPA 99 (2021 Edition) security management requirements by not maintaining an annually updated and reviewed Security Vulnerability Assessment (SVA). During record review between 9:15 AM and 1:30 PM with the Maintenance Director and the Administrator, surveyors requested documentation showing that the SVA had been updated and reviewed each year, as required by Section 13.3 of NFPA 99. The facility was unable to provide such documentation, and both the Maintenance Director and the Administrator acknowledged that the Security Vulnerability Assessment had not been updated and reviewed annually. This deficiency was cited as a Class III violation and was noted as having the potential to affect all occupants in the facility in case of a fire or other emergency. No specific residents, medical histories, or clinical conditions were mentioned in the report, and the deficiency pertained to facility-wide security and emergency preparedness documentation rather than to individual patient care events.
Plan Of Correction
Security vulnerability assessment was reviewed and a signature page was placed in the binder. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct a three month check to verify completion of documentation.
Deficiency in Nutritional Assessment Process
Penalty
Summary
The facility failed to ensure that clinical nutritional assessments were completed within the appropriate scope of practice, affecting one resident reviewed for nutrition and potentially impacting 51 out of 60 residents. The Certified Dietary Manager (CDM) conducted quarterly nutritional assessments for a resident with multiple diagnoses, including Diabetes, Hypertension, Congestive Heart Failure, and Anemia, without oversight or review by the facility's Dietitian. The CDM completed these assessments using a formula provided by the Dietitian but did not have the assessments signed off by the Dietitian. Interviews revealed that the CDM was responsible for most quarterly assessments, while the Dietitian handled initial, annual, and specific cases such as tube feedings, dialysis, and weight loss. The Dietitian was unaware that the CDM should not perform quarterly assessments without oversight. The CDM communicated with the Dietitian regarding weight changes but did not have the assessments formally reviewed or acknowledged by the Dietitian, leading to a deficiency in the facility's nutritional assessment process.
Failure to Follow Approved Menu and Provide Alternate Meal Options
Penalty
Summary
The facility failed to adhere to their approved menu during a lunch meal service, affecting the nutritional needs of residents. On the observed date, the approved menu included BBQ ribs with baked beans and an alternate meal of fried fish with corn on the cob. However, the actual meal served included chicken thighs and green beans, with no corn on the cob, carrots, or lima beans prepared as per the menu. The lead cook admitted to substituting green beans for carrots and chicken for fish, citing resident preferences, but could not explain the absence of corn on the cob or lima beans. The kitchen manager confirmed the availability of corn on the cob in the freezer but had no explanation for its omission, and acknowledged the lack of carrots and lima beans. The deficiency affected residents who had documented dislikes for pork, as the main entree was pork BBQ ribs. One resident who disliked pork was served fried fish, while others received chicken, contrary to the documented alternate meal. Interviews with residents revealed dissatisfaction with the meal substitutions, as one resident expressed a preference for the corn on the cob that was not served. Another resident confirmed receiving chicken without being informed of the alternate meal option of fried fish, which he preferred. The kitchen manager acknowledged the oversight in meal preparation and confirmed the mechanical soft and pureed vegetable options should have been corn, aligning with the alternate vegetable choice.
Failure to Implement Enhanced Barrier Precautions and Ensure Hand Hygiene
Penalty
Summary
The facility failed to implement an Enhanced Barrier Precaution (EBP) process for residents with wounds and indwelling medical devices, affecting four sampled residents and potentially impacting six residents identified as needing EBP. This deficiency was observed in residents with conditions such as dementia, end-stage renal disease, and urinary catheter use. The facility's infection preventionist admitted that the EBP process was not in place until after the surveyor's intervention, indicating a lack of adherence to infection control practices. Resident #22, who was receiving tube feeding, was observed multiple times without any EBP measures in place, such as signage or a PPE kit. Similarly, Resident #44, who had a stage four pressure ulcer, was observed without EBP measures during wound care. Staff involved in the care of Resident #44 did not wear gowns, and hand hygiene was not performed between glove changes, contrary to the facility's policy. The staff's lack of understanding and adherence to EBP and hand hygiene protocols contributed to the deficiency. Additionally, Resident #1, who had a urinary catheter, was observed without EBP measures, and staff were unaware of the necessary PPE requirements. Interviews with staff revealed a lack of awareness and understanding of EBP, with some staff unable to locate necessary PPE supplies. The facility's failure to ensure appropriate infection control practices and staff education on EBP and PPE use led to the identified deficiencies.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in their care. Resident #15, who was admitted with dementia, was inaccurately assessed as having no impairment in upper extremities, despite therapy evaluations and care plans indicating the need for a right-hand splint and passive range of motion exercises due to right-sided weakness. Observations confirmed the resident's right hand was tightly closed with contracture, and no splint was in place, contradicting the MDS assessment. The MDS Coordinator acknowledged the discrepancy during a review. Resident #33, admitted with hypertension, was recorded in the MDS as having adequate hearing, despite care plans and progress notes indicating severe hearing loss. Observations and family interviews confirmed the resident's inability to hear and lack of hearing aids, which were discarded. The MDS Coordinator agreed with the incorrect coding. Additionally, Resident #8, who was on anti-platelet medication for a stroke, had no documentation of this medication in the MDS assessment, although the Medication Administration Record confirmed its administration. The MDS Coordinator acknowledged the failure to code the medication correctly.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop adequate care plans for two residents, leading to deficiencies in their care. Resident #58, who had severe cognitive impairment and a history of falls, experienced a fall resulting in a thumb dislocation. Despite the incident, the care plan was not updated to address the actual fall with injury or the necessary splint care. The MDS Coordinator acknowledged the absence of a specific care plan for the significant injury from the fall and the lack of a care plan related to splint care. Resident #17 was observed using bed side rails, but the facility did not include this in the resident's care plan. The MDS Coordinator, who was new to the facility, noted inconsistencies in the care plans and agreed that the use of bed side rails should have been documented. The failure to include the use of bed side rails in the care plan for Resident #17 was acknowledged during the survey.
Deficiency in Catheter Care and Personal Hygiene
Penalty
Summary
The facility failed to provide complete and proper personal care for a resident with a urinary drainage device. The deficiency was identified during an observation of personal care provided by a Certified Nursing Assistant (CNA) to a resident who was cognitively impaired and totally dependent on staff for toileting. The CNA did not perform hand hygiene before donning gloves, which is a requirement according to the facility's policy on Foley catheter care and maintenance. Additionally, the CNA did not provide peri-care during the catheter care process, which is essential to prevent complications such as infections. The resident, who had an indwelling urinary catheter due to bladder obstruction, was observed in bed with urinary catheter tubing and bedside drainage. The CNA cleaned the urinary catheter tubing and the resident's left groin but failed to perform any peri-care. When questioned, the CNA admitted to not providing any personal care for the resident that morning and confirmed the lack of hand hygiene before donning gloves. The resident's care plan noted a potential for complications related to the use of an indwelling catheter, and it was updated to reflect colonization with E. Coli, indicating a lapse in proper catheter care.
Failure to Ensure Safe Cooking Temperature for Fried Fish
Penalty
Summary
The facility failed to follow proper cooking instructions and ensure that prepared fried fish was at a safe temperature for a resident who ordered the meal. The production recipe for the breaded cod specified that the fish should be deep-fried from frozen at 360 degrees F for 3 to 5 minutes, with a final internal cooking temperature of at least 145 degrees F, held for a minimum of 15 seconds. Additionally, hot foods held for later service must maintain a minimum internal temperature of 135 degrees F. During the lunch meal service, the lead cook placed prepared foods into the steam table and stated that the fried fish would be cooked later, as the resident who requested it was served on the last cart. At approximately 12:00 PM, the assistant cook fried three pieces of fish and placed them on the steam table without obtaining a final temperature. When the surveyor requested the temperature of the fish at 12:14 PM, it was found to be 125 degrees F, which was below the required safe temperature. The lead cook instructed the assistant cook to fry the fish longer, and after further cooking and surveyor intervention, the temperature reached 164 degrees F. The Kitchen Manager/Certified Dietary Manager acknowledged that the staff failed to properly check the temperature of the fried fish upon completion of cooking and did not hold the cooked fish at a safe temperature.
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pahokee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vivo Healthcare Clewiston | 18 mi | ★★★★★ | 0 | 0 |
| Okeechobee Health Care Facility | 27.4 mi | ★★★★★ | 1 | 0 |
| Royal Palm Beach Health And Rehabilitation Center | 29.2 mi | ★★★★★ | 0 | 0 |
| Luxe At Wellington Rehabilitation Center The | 30.6 mi | ★★★★★ | 2 | 0 |
| Chatsworth At Pga National | 32.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.