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 Heartland Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, a right ankle fracture, and a right thigh wound was care planned for skin integrity and musculoskeletal issues, including monitoring of skin injuries, wound characteristics, and use of a cast and supportive wraps. The resident was later observed pulling an ace wrap up the leg, causing discoloration, and subsequently developed a traumatic circular ulcer after tightening gauze supporting a soft cast, with Mupirocin ointment applied. Facility records lacked evidence that the cast, ace wrap, or Kerlex wrap were monitored, there was no physician order for the Mupirocin, and only one dressing change for the right thigh wound was documented, with no recorded wound size, location, or ongoing treatment, as acknowledged by the DON.
The facility failed to maintain grooming and personal hygiene for several residents, leading to deficiencies in care. A resident with dementia was observed with dirty hair despite records indicating it had been washed. Another resident's hair was greasy and unkempt, requiring more frequent washing. Two residents were not checked for incontinence, resulting in soiled briefs and potential skin issues. A resident's nails were found dirty with feces, indicating a lack of proper hygiene care.
The facility failed to provide food in a form that met the needs of residents on pureed diets. Two residents with severe cognitive impairments and dysphagia were served meals that did not adhere to the facility's policy for smooth, homogenous pureed textures. The Senior Dining Services Manager confirmed the deficiency during an interview.
The facility failed to follow its infection control program, impacting five residents. There were no physician orders for Enhanced Barrier Precautions for residents with pressure ulcers and a urinary catheter. A resident with severe cognitive impairment had a mishandled urinary catheter, leading to discomfort. An LPN did not perform hand hygiene during eye drop administration. The laundry area was not maintained to prevent infection spread, with issues like rusted equipment and debris accumulation.
A resident with severe cognitive impairment alleged that a CNA hurt her by grabbing her arm. The facility failed to report the allegation to authorities within the required two-hour timeframe. Despite an internal investigation finding no physical evidence, the delay in reporting was attributed to waiting for case numbers from authorities.
The facility failed to provide appropriate care for three residents, leading to deficiencies in treatment and comfort. A resident was improperly positioned in a wheelchair, another had a splint incorrectly applied, and a third experienced low blood glucose levels without proper intervention documentation. Communication and documentation issues were evident, impacting resident care.
A resident with dementia and dysphagia, at risk for malnutrition, experienced significant weight loss and showed signs of malnutrition despite consuming all meals. Observations revealed the resident finished meals quickly and scraped pudding cups for more food, yet staff did not offer additional nourishment. The facility failed to monitor and adjust nutritional interventions effectively.
A resident dependent on a PEG tube for nutrition was receiving enteral feeding without a physician's order, contrary to facility policy. The resident, with severe cognitive impairment, was observed receiving Jevity 1.5 Cal at 47 ml/hr. Staff interviews revealed the feeding was administered based on routine practice rather than a documented order, which was confirmed by the ADON.
A resident with a left hip fracture experienced severe pain during personal care due to the facility's failure to implement non-pharmacological interventions. Despite being on routine Tramadol, the resident cried out in pain when turned by CNAs, who did not use positioning techniques suggested by the PT. The care plans lacked instructions to minimize pain, and staff were unaware of measures to reduce discomfort during care.
Failure to Monitor and Properly Treat Trauma Wound and Supportive Leg Dressings
Penalty
Summary
The deficiency involves the facility’s failure to monitor and implement appropriate treatment and obtain timely physician-directed services for a resident’s trauma wound. The resident, who had severe cognitive impairment and required substantial to maximum assistance with activities of daily living, was care planned for potential skin integrity impairment related to incontinence and cognition, with interventions to monitor and document skin injuries and report abnormalities and failure to heal to the physician. The resident was also care planned for an alteration in musculoskeletal status due to a right inner malleolus fracture, with interventions to use supportive devices such as a cast and to monitor circulation, motor function, and sensation, and later care planned for a right thigh wound with instructions to monitor and document the wound’s location, size, and treatment. Record review showed that on one date the resident was observed pulling an ace wrap from the right lower leg up toward the knees, causing wide discoloration to the upper knees; the resident was on Plavix and considered high risk for discoloration, and the ace wrap was changed to Kerlex. A subsequent progress note documented a traumatic circular ulcer on the right leg that occurred when the resident tightened gauze supporting the soft cast, with Mupirocin ointment applied and instructions to monitor the dressing and have wound care evaluate and treat. However, there was no evidence that the cast, ace wrap, or Kerlex wrap were being monitored, no physician order for Mupirocin was found, and the only documented dressing change for the right thigh wound occurred once, with no documentation of ongoing monitoring, wound size, location, or treatment. The DON acknowledged these findings during interview.
Deficiencies in Resident Grooming and Hygiene Care
Penalty
Summary
The facility failed to maintain grooming and personal hygiene for several residents, leading to deficiencies in care. Resident #53, who was severely cognitively impaired, was observed with dirty, flat, and greasy hair despite documentation indicating that hair washing had been completed. Staff H, a CNA, admitted to misunderstanding the task and only providing a washcloth wipe instead of a proper hair wash. The Assistant Director of Nursing and the Director of Nursing acknowledged the oversight and agreed that the resident's hair should have been washed properly. Resident #17, also severely cognitively impaired, was found with greasy and unkempt hair despite records showing hair washing had been completed. Staff I, a CNA, noted that the resident's hair always appeared greasy due to its type and agreed it should be washed more frequently than scheduled. This indicates a failure to provide adequate grooming care as per the resident's needs. Residents #55 and #79, both dependent on staff for all ADLs, were not checked for incontinence throughout the day, resulting in soiled briefs and strong odors. Staff K and Staff L, CNAs, failed to ensure these residents were clean and dry, leading to potential skin integrity issues. Resident #80, who required substantial assistance for personal hygiene, was observed with dirty nails containing debris, which was later identified as feces by the resident's family member. Staff R, a CNA, did not provide a satisfactory explanation for the lack of nail care, highlighting a deficiency in maintaining the resident's personal hygiene.
Failure to Provide Proper Pureed Diets
Penalty
Summary
The facility failed to provide food in a form that met the individual needs of residents on pureed texture diets, as observed in two residents. Resident #43, who was diagnosed with Sarcopenia, Dementia, and Oral Dysphagia, was served a dinner where the pureed bread was lumpy, contrary to the facility's policy for pureed diets. This policy specifies that all foods should be smooth in texture and free from whole, minced, or ground pieces. Resident #43's care plan, which focused on nutrition related to dysphagia and malnutrition risk, was not adhered to in this instance. Similarly, Resident #57, who was receiving hospice services and had diagnoses including Alzheimer's disease and Dementia, was served a dinner where the pureed meat contained small pieces and the pureed bread was lumpy. This was inconsistent with her prescribed diet order for a pureed texture. The Senior Dining Services Manager confirmed these findings during an interview and tasting session, acknowledging that the pureed foods were not smooth and homogenous as required by the facility's policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection control program, impacting five out of seven sampled residents. Specifically, the facility did not ensure physician orders for Enhanced Barrier Precautions (EBP) for residents with pressure ulcers and an indwelling urinary catheter. The Director of Nursing (DON) and Assistant DON (ADON) were unable to locate current orders for EBP for these residents, and the ADON indicated that Unit Managers were typically responsible for entering these orders. Additionally, the facility did not properly maintain the indwelling urinary catheter for a resident who had a severe cognitive impairment and a urinary tract infection. Observations revealed that the urinary catheter drainage bag was improperly placed on a dirty fall mat, and staff failed to report this to the nurse. During personal care, the catheter was detached and mishandled, causing discomfort to the resident, and the new drainage bag was connected without proper sanitization. The facility also failed to ensure proper hand hygiene during medication administration. An LPN did not perform hand hygiene or wear gloves while administering eye drops to a resident. Furthermore, the laundry area was not maintained to prevent infection spread, with issues such as lack of hand hygiene signage, rusted equipment, and debris accumulation. The Environmental Services Director acknowledged these concerns during a tour of the laundry area.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner involving a resident with severe cognitive impairment. The resident, who had a history of multiple medical conditions including dementia, reported that a Certified Nursing Assistant (CNA) hurt her by grabbing her arm. Despite the resident's cognitive impairment and inconsistent recollection of the event, the allegation was not reported to the appropriate authorities within the required two-hour timeframe. Interviews with staff revealed that the Licensed Practical Nurse (LPN) was informed of the incident and subsequently reported it to the Director of Nursing (DON). The DON confirmed the incident was reported to her but delayed speaking with the CNA involved due to her being on break. The CNA denied any inappropriate contact, stating she only assisted the resident with clothing. The facility conducted an internal investigation, which included a head-to-toe assessment of the resident, finding no physical evidence to support the allegation. The Administrator reported the incident to the Department of Children and Families (DCF) and Law Enforcement, but both agencies declined to accept the case. The Administrator noted inconsistencies in the resident's account and a lack of physical evidence. The delay in reporting was attributed to waiting for case numbers from the authorities, which is not in compliance with the facility's policy requiring immediate reporting of abuse allegations within two hours.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care and services for three residents, leading to deficiencies in their treatment and comfort. Resident #95 was observed in a high back wheelchair with improper positioning, causing discomfort and sliding down in the chair. Despite being aware of the issue, the Director of Rehabilitation had not yet addressed the problem. The resident had a fixed left knee contracture and was discharged from physical therapy, but the facility did not ensure proper positioning to maintain comfort. Resident #11 was on a Functional Maintenance Program requiring the use of a left-hand resting splint to reduce swelling and pain. However, observations revealed that the splint was either not worn or incorrectly applied, with the resident's fingers bent into a fisted position. Staff were not adequately documenting the use of the splint, and there was a lack of communication between the therapy department and nursing staff, as evidenced by the absence of the splint information in the facility's Kardex system. Resident #18, who had severe cognitive impairment and diabetes, experienced repeated low blood glucose levels without appropriate interventions being documented. The facility's policy did not provide procedures for following physician's orders for low blood sugar levels, and there was a lack of readily available orange juice for intervention. Staff A, LPN, acknowledged giving the resident orange juice but did not document the intervention or recheck the blood glucose levels until lunchtime, failing to follow the physician's orders for immediate rechecking after intervention.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of a resident diagnosed with dementia and dysphagia, who was at risk for malnutrition and aspiration. The resident experienced significant weight loss, dropping from 183 lbs to 149.4 lbs, with a BMI of 20.8, indicating underweight status for his age. Despite consuming 100% of his meals in most instances, the resident displayed signs of malnutrition, such as visible muscle wasting. Observations revealed that the resident consistently finished his meals quickly and scraped his pudding cup for more food, indicating a possible need for increased portions. However, staff did not offer additional food or fluids, and the resident's nutritional interventions were not effectively monitored or adjusted. During meal observations, the resident was seen consuming his meals rapidly and was not provided with additional food despite clear indications of hunger. Staff removed the resident from the dining area and cleared his dishware, including unfinished fluids, without offering more nourishment. A nurse supervisor acknowledged the resident's behavior of scraping the pudding cup but only suggested informing the registered dietitian without taking immediate action. The facility's failure to monitor and adjust the resident's nutritional interventions contributed to the deficiency in providing adequate nutrition to maintain the resident's health.
Lack of Physician's Order for Enteral Feeding
Penalty
Summary
The facility failed to have a physician's order for the administration of enteral feeding for a resident who was dependent on a PEG tube for nutrition. The facility's policy required a doctor's order for enteral feeding, but this was not in place for the resident in question. The resident, who had severe cognitive impairment and was dependent on tube feeding for more than 51% of their nutrition, was observed receiving Jevity 1.5 Cal at 47 ml/hr without a documented order in the medical records. Interviews with staff revealed that the Registered Nurse Supervisor administered the feeding based on routine practice rather than a specific physician's order. The Assistant Director of Nursing confirmed the absence of a current order for the tube feeding formula, acknowledging the oversight. The deficiency was identified during a review of the resident's care plan, medical records, and observations, highlighting a lapse in following the facility's policy for enteral feeding orders.
Failure to Implement Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to provide non-pharmacological interventions to reduce pain during personal care for a resident with a left hip fracture. The resident, who was admitted after a fall at home, has severe cognitive impairment and is dependent on staff for care involving her lower extremities. Despite being on routine Tramadol for pain management, the resident experienced excruciating pain during personal care, as observed when CNAs turned her to her right side, causing her to cry out in pain. The care plans did not include instructions on how to turn the resident to minimize pain, and the CNAs did not implement any measures to alleviate the pain during the observed care. Interviews with staff revealed a lack of awareness and implementation of positioning techniques that could reduce the resident's pain during care. The Physical Therapist suggested that placing pillows between the resident's legs could help alleviate pain, but this was not known or practiced by the CNAs or the LPN involved in the resident's care. The LPN admitted to being unaware of any measures suggested by therapy to reduce pain during personal care, indicating a communication gap between therapy and nursing staff regarding pain management strategies for the resident.
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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 Boynton Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Boynton Beach Rehabilitation Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Isles Of Boynton Nursing And Rehab Center | 2.4 mi | ★★★★★ | 9 | 0 |
| Boulevard Rehabilitation Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Hamlin Place Of Boynton Beach | 3.1 mi | ★★★★★ | 10 | 0 |
| Vi At Lakeside Village | 3.7 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.