Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Isles Of Boynton Nursing And Rehab Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including a fracture, pressure ulcer, acute kidney failure, and type 2 DM, had a physician order for ascorbic acid 500 mg PO daily for wound healing. During a med pass, an LPN prepared Saccharomyces boulardii 500 mg, a probiotic for which there was no order, intending to administer it to the resident until a surveyor intervened. The LPN reported she believed ascorbic acid and Saccharomyces boulardii were the same medication, later confirming that ascorbic acid is Vitamin C and acknowledging it was not the ordered drug, demonstrating failure to follow the facility’s medication administration policy and the right medication standard.
Improper wound care technique during pressure ulcer treatment: A resident with quadriplegia, chronic osteomyelitis, severe malnutrition, and multiple pressure ulcers received wound care that did not follow the ordered treatment. The wound care RN cleansed the wound beds and surrounding skin with Dakin’s solution, reused the same tongue depressor across all 3 wounds to apply silver gel, applied gel to peri-wound skin, and placed one long Dakin’s-soaked gauze strip across healthy skin between the wounds. The wound care NP stated the peri-wound should not have been cleansed with Dakin’s, the silver gel should not have been applied to peri-wound skin, and the gauze should have been limited to each wound bed.
Failure to secure an indwelling urinary catheter: A resident with quadriplegia, chronic osteomyelitis, pressure ulcer, severe protein-calorie malnutrition, major depressive disorder, and moderate cognitive impairment had an order for catheter anchor/securement device care. During wound care observation, the catheter was found not anchored, and a CNA then removed the adhesive backing and secured the catheter tubing to the resident's upper thigh after noticing it was not attached.
A resident with a midline for IV fluids had a dirty dressing with dried blood under it, and the dressing had been in place longer than the facility’s weekly change interval. The resident said no one had changed the dressing since insertion and that the IV hurt and pinched her skin. Staff, including LPNs, an RN, the ADON, and the DON, stated IV dressings for PICCs and midlines should be changed weekly and as needed, and they agreed the dressing was bloody, dirty, and needed to be changed. The record also lacked IV monitoring orders and an IV care plan.
Failure to perform ordered trach care occurred when an LPN completed tracheostomy care for a resident with severe cognitive impairment, anoxic brain damage, and acute respiratory failure without doing a respiratory assessment or suctioning despite visible secretions and a mucus plug. The resident had active orders for oxygen via trach collar, trach care, and suctioning every shift and as needed, and the LPN stated she was nervous and did not suction even though she knew she should have.
Unauthorized access and improper medication storage were observed when a WCRN gave treatment cart keys to a CNA who was not authorized to access medications, an LPN left a med cart unlocked and unattended during med pass, and a resident had multiple OTC meds stored at the bedside without an order or self-administration assessment. The resident had diagnoses including a left talus fracture, pressure ulcer, AKI, and DM2, and had a BIMS score of 15.
Failure to Serve Ground Meats per Diet Order: A resident with dementia, cerebral atherosclerosis, sarcopenia, and hospice services had a diet order for regular texture foods with ground meats added for ease of chewing, but the facility's meal tickets did not reflect the ground meat order. During observations, the resident was served regular texture beef pot pie and later whole sausage patties instead of ground meats, and staff relied on the meal ticket rather than the EMR diet order.
Three discharged residents did not receive timely refunds for overpaid amounts, as confirmed by the facility's Aging Report and interviews with the BOM. Despite repeated inquiries from a resident's family and internal awareness of the outstanding balances, the refunds were not processed within the required timeframe.
A resident with severe cognitive impairment and a history of exit-seeking behavior was inadequately supervised, leading to a fall from a window. Despite previous incidents of wandering and exit-seeking, the resident was not placed on one-to-one observation after being moved to a secured floor. Staff failed to communicate and document the resident's behavior, resulting in the resident removing a window panel and falling 20 feet, sustaining serious injuries.
A resident with a history of traumatic brain injury and exit-seeking behavior fell from a second-floor window due to inadequate supervision. Despite being moved to a secured floor, the resident was not placed on one-to-one observation, leading to the incident. Staff failed to recognize exit-seeking behavior and did not document or communicate the resident's needs effectively.
A resident with severe cognitive impairment and dependency on staff for daily activities suffered a knee fracture, which was not investigated by the facility. Despite the resident's complaint of knee pain and subsequent positive X-ray results, the incident was not documented in the facility's adverse and incident log. The ADON suggested osteoporosis as a cause but lacked documentation, and the injury was not investigated as per policy.
The facility did not conduct Level I PASARR screenings for two residents with mental disorders or intellectual disabilities, as required for those needing extended care. One resident had severe cognitive impairment, and another had a psychotic disorder, yet neither had the necessary preadmission screening. The absence of these screenings was confirmed by facility staff.
A resident experienced itching and burning in her genitals after a urinary catheter change, which she believed to be a yeast infection. Despite informing the nurse and being promised treatment, she did not receive any medication and resorted to using an antibiotic cream prescribed for her toe. There was no documentation of her complaints or treatment orders, and the Unit Manager was unaware of her concerns. An observation revealed her genitals were reddened, inflamed, and bleeding.
The facility failed to provide behavior monitoring for two residents prescribed antipsychotic medications. One resident with severe cognitive impairment was on Seroquel for depression, but no behavior monitoring was documented. Another resident with psychotic and depressive disorders was on Duloxetine and Pimavanserin, yet lacked behavior monitoring documentation. This indicates non-compliance with monitoring policies.
A resident was found with unsecured Gentamycin ointment in her bedside drawer, which she was using inappropriately. The resident, who was alert and oriented, admitted to using the ointment for relief of itching and burning on her genitals instead of her prescribed toe. The Unit Manager acknowledged that medications should not have been unsecured at the bedside.
A resident with mild cognitive impairment and physical limitations was not assisted out of bed for 14 days due to a lack of coordination between rehabilitation and nursing staff. The PT did not communicate the need for a hoyer lift and specialized chair to the CNA, and the ADON had not documented efforts to order the necessary chair.
A resident's physician-ordered vital signs and cough secretions monitoring were not accurately documented, revealing inconsistencies and omissions in the facility's records. Interviews with staff showed a lack of clarity and accountability in the documentation process, with vital signs not recorded on several days and missing details about the resident's condition. The Assistant DON could not explain the incomplete documentation, indicating a deficiency in the facility's practices.
The facility failed to follow CDC guidelines for infection control, with staff not adhering to Contact and Enhanced Barrier Precautions for three residents. A maintenance worker entered a resident's room without PPE, a nurse used shared equipment against guidelines, and a CNA misunderstood precaution requirements, leading to breaches in infection control.
A resident with a UTI experienced a delay in treatment due to the facility's failure to obtain urinalysis results in a timely manner. The resident, who was frequently incontinent of urine, had an order for a urinalysis culture and sensitivity, but the results were not available until five days later. The resident was prescribed an antibiotic only after the results were received. An interview with the Desk Nurse indicated that preliminary results should have been followed up within 24-48 hours, but this did not occur.
Incorrect Medication Prepared Due to Misidentification of Ascorbic Acid
Penalty
Summary
The deficiency involves a failure to ensure correct medications were given according to physician orders, resident preferences, and goals for one resident during a medication administration observation. Facility policy on Clinical-Medication Administration required nurses to have a working knowledge of medications, including common dosage, uses, side effects, and the reason for administration, and to observe the rights of medication administration, including the right medicine. Resident #155 had been admitted with diagnoses including a displaced avulsion fracture of the left talus, a pressure ulcer, acute kidney failure, and type 2 diabetes mellitus, and had a Brief Interview of Mental Status score of 15, indicating intact cognition. The physician’s orders included ascorbic acid 500 mg by mouth once daily for wound healing, and there was no order for Saccharomyces boulardii 500 mg. During a medication pass observation, an LPN prepared Saccharomyces boulardii 500 mg and entered the resident’s room intending to administer it, despite there being no order for this medication for the resident. The surveyor intervened before the wrong medication was given, preventing administration. In a subsequent interview, the LPN stated she believed ascorbic acid 500 mg was the same as the probiotic Saccharomyces boulardii 500 mg. When asked for another name for ascorbic acid, the LPN looked it up, identified it as Vitamin C, and acknowledged it was not the same medication, confirming a lack of correct knowledge and verification of the ordered drug prior to administration.
Improper wound care technique during pressure ulcer treatment
Penalty
Summary
The facility failed to provide wound care for a resident with multiple pressure ulcers in a manner consistent with professional standards of practice and the physician’s orders. The resident had diagnoses including quadriplegia, chronic osteomyelitis of the left thigh, pressure ulcer of unspecified site, severe protein calorie malnutrition, and major depressive disorder, and the MDS documented moderate cognitive impairment. The ordered treatment for the sacrum, right ischium, and left ischium included cleansing with Dakin’s solution, applying hydrogel or SilvaSorb to the wound bed, and covering with silicone foam dressing. During observed wound care, the wound care RN used Dakin’s-soaked gauze to cleanse not only the wound beds but also the surrounding skin of all three wounds. He removed and reapplied gloves after touching the privacy curtain, then used the same tongue depressor repeatedly to remove silver gel from a medication cup and apply it to all three wounds and surrounding skin. The RN also placed silver gel on the peri-wound area, and the wound care NP stated the peri-wound should not be cleansed with Dakin’s solution, the silver gel should not be applied to the peri-wound, and the same tongue depressor should not be used across multiple wounds because it could cross-contaminate the wounds. The RN then soaked a single long piece of gauze in Dakin’s solution and placed it across the right ischium wound, over healthy skin, onto the sacral wound, across more healthy skin, onto the left ischium wound, and back again, rather than placing it only in each wound bed. The dressing was then covered with two bordered dressings, but the gauze between the sacrum and right ischium was not completely covered. The wound care NP stated this approach would destroy healthy tissue between the wounds and that all gauze and the wound should be covered because the resident had stool incontinence despite a colostomy. The RN later stated he realized he could improve in some areas with the wound care he provided.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that an indwelling urinary catheter was secured in place for one resident. The resident had diagnoses including quadriplegia, chronic osteomyelitis of the left thigh, pressure ulcer of unspecified site, severe protein calorie malnutrition, and major depressive disorder, and the MDS documented moderate cognitive impairment with a BIMS score of 12. The resident had an order dated 02/05/26 for urinary catheter care that included changing catheter anchor or securing devices as needed and encouraging and assisting the resident to use or apply the securing device as tolerated. During an observation of wound care on 02/11/26, the resident's indwelling urinary catheter was observed to be not anchored. After the wound care was completed, the CNA removed the adhesive from the anchor that was on the catheter tubing and secured the catheter to the resident's upper right thigh. During interview, the CNA stated she noticed the catheter was not attached to the resident, so she removed the backing and adhered the anchor to the resident's leg to secure the tubing.
Dirty Midline Dressing Not Changed as Ordered
Penalty
Summary
The facility failed to maintain a sanitary IV access dressing and failed to change the dressing according to facility policy for one resident with a midline. The resident was admitted with a diagnosis of heart failure and had a BIMS score of 13, indicating cognitive intactness. Orders showed a peripheral/midline was inserted for IV fluids for hypotension and persistent AKI, and the midline was later discontinued. The record did not contain orders for IV dressing changes or IV monitoring/assessment, and the care plan did not include IV or midline care since admission. During observation, the resident had a right upper arm midline with a dressing that appeared dirty and had dried dark red blood underneath it. The dressing was dated 01/29, which was 11 days earlier. The resident stated that medications had been completed the prior week, that nurses told her they could not remove the line without a doctor’s order, and that no one had changed the dressing since insertion. The resident also stated, "It hurts and it is pinching my skin." The resident later stated the IV was removed and her arm felt better after it was taken out. Staff interviews showed nurses and the ADON stated IV assessments were done every shift and that IV dressings for PICCs and midlines were changed weekly and as needed. Staff also stated they would expect to see a dressing change order and a care plan for a resident with an IV. When shown the resident’s IV dressing, multiple staff members described it as bloody, dirty, crusty, yucky, and needing to be changed. The DON agreed with the findings and stated she would look for the care plan, and later acknowledged there was no care plan for the resident’s midline.
Failure to Perform Ordered Tracheostomy Assessment and Suctioning
Penalty
Summary
Safe and appropriate respiratory care was not provided for a resident with a tracheostomy when staff failed to follow physician orders and facility policy during tracheostomy care. The resident was admitted with anoxic brain damage and acute respiratory failure with hypoxia, had severe cognitive impairment, and had active orders for oxygen via trach collar at 4 LPM as tolerated every shift, trach care every shift and as needed, and suctioning every shift and as needed. The care plan directed staff to monitor and document respiratory status, obtain and report vital signs as ordered and as needed, and provide suctioning as ordered and tolerated. During an observed tracheostomy care session, an LPN performed hand hygiene and donned a gown and gloves, set up supplies, and began tracheostomy care, but did not perform a respiratory assessment. While cleaning the trach collar, the resident began coughing and expelling secretions, and a mucus plug was visualized. The LPN wiped secretions from the top of the trach cannula and observed continued coughing with small amounts of secretions expelled across the room, stated she should suction the resident, but did not suction the resident. She checked the pulse oximetry and stated it was 97%, then completed the care and left the room without performing a respiratory assessment. In interview, the LPN stated this was the first time she had performed tracheostomy care by herself on a resident and that she had last trained for it in 2022. She stated she knew how to suction and perform respiratory assessments but did not do so because she was nervous and believed she had only done a dressing change. Her competency validation for trach care documented that she was to assess HR, RR, SaO2, and lung sounds, remove soiled dressing, assess the stoma site, suction if necessary, and reassess the patient, and it was signed off as acceptable. The DON agreed with the findings and stated the nurses needed more education.
Unauthorized Access and Improper Medication Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and accessed in accordance with policy and accepted principles. During wound care for Resident #21, Staff A, a WCRN, gave his keys to Staff B, a CNA, so she could stock the medication treatment carts. Staff A stated this was how they worked and that she was part of his team, while Staff B said she was going to restock the treatment carts. The Director of Human Resources confirmed Staff B was not a Qualified Med Tech and had no job description authorization to access medications, including treatment carts. The facility also failed to keep one of eight med carts locked when a nurse left it unlocked and unattended while entering a resident’s room to administer medications. The facility further failed to secure medications at the bedside for Resident #155. The resident was admitted with diagnoses including displaced avulsion fracture of the left talus, pressure ulcer of another site, acute kidney failure, and type 2 diabetes mellitus, and the MDS documented a BIMS score of 15. The record showed no assessment for self-administration of medications, and the physician’s orders included only ascorbic acid 500 mg daily for wound healing. During a medication pass, several over-the-counter medications were observed on the resident’s overbed table in an open clear container, including magnesium gummies, tension headache relief acetaminophen, Tums extra strength, Benadryl Allergy tablets, and Vicks nasal solution. The LPN acknowledged the medications were at the bedside and that the resident had no order or assessment for self-administration.
Failure to Serve Ground Meats per Diet Order
Penalty
Summary
The facility failed to serve ground meats according to a physician's diet order for a resident who was on a regular diet with regular texture foods and thin liquids, with ground meat added on 08/06/25 at the request of his daughter for ease of chewing. The resident had been admitted with diagnoses including cerebral atherosclerosis, unspecified dementia with behavioral disturbance, and sarcopenia, and had also been receiving hospice services since 09/09/2022. A review of the resident's diet in the facility's meat ticket program showed only a regular diet with regular texture food and regular/thin liquids, and did not reflect the ground meat order. During observation, the resident was found chewing a large piece of food and removed brown chewed-up food from his mouth that appeared to be half of a small hamburger. The CNA stated she had just finished feeding him, and the tray retrieved from the cart showed a meal ticket listing a regular diet with regular texture foods and thin fluids. The resident had been served regular texture beef pot pie, and the leftover food included stringy beef that should have been ground. On a later observation, the resident was served whole waffles, corn flakes, and two whole round sausage patties, again matching the meal ticket rather than the ground meat order. A CNA stated she believed the resident's diet was identified by the meal ticket and found that the diet was not listed in the Kardex.
Failure to Timely Issue Refunds to Discharged Residents
Penalty
Summary
The facility failed to issue refunds to discharged residents or their representatives within 30 days, as required. Record review and interviews revealed that three residents who were discharged from the facility had not received refunds for overpaid amounts. One resident was discharged to an assisted living facility, and the family member confirmed that despite multiple calls and emails to the Business Office Manager (BOM), the refund had not been received. The BOM acknowledged that a request for the refund was not sent to the corporate biller until two months after discharge, partly due to communication issues with the previous BOM. The Aging Report confirmed that the resident was owed $4,888.20. Further review showed that two additional residents were also owed refunds of $2,177.64 and $871.18, respectively, after their discharges. The BOM confirmed that these refunds had not been processed, as the amounts remained on the Aging Report. The BOM stated that she was aware of the outstanding refunds and agreed with the findings. Photographic evidence was obtained to support the deficiency.
Neglect Due to Inadequate Supervision of Exit-Seeking Resident
Penalty
Summary
The facility failed to protect a resident from neglect by not providing appropriate supervision for a resident who displayed exit-seeking behaviors. The resident, who had a history of traumatic brain injury and severe cognitive impairment, was admitted with diagnoses including traumatic subarachnoid hemorrhage and major depressive disorder. Despite being identified as having wandering behavior, the resident was moved to a secured floor without continued one-to-one observation, which was initially implemented due to exit-seeking behavior. On the morning of the incident, the resident was observed wandering and attempting to exit the building, setting off an alarm. However, the staff did not reinstate one-to-one observation, and the resident was left unsupervised. The resident managed to remove a window panel and fell approximately 20 feet to the ground, sustaining serious injuries. Interviews with staff revealed a lack of communication and documentation regarding the resident's exit-seeking behavior and the necessary supervision required. The staff, including LPNs and CNAs, were not adequately informed or trained to recognize and respond to exit-seeking behaviors effectively. The facility's failure to maintain appropriate supervision and communication among staff members contributed to the resident's ability to exit through the window, resulting in the fall and subsequent injuries.
Removal Plan
- Resident was assessed and 911 called to transport to hospital for higher level of care.
- Director of Nursing (DON) notified Interim Administrator, Regional Director of Operations (RDO), Nurse Consultant, President of Clinical Services of incident.
- The Facility conducted a head count of residents currently residing in the facility, all were accounted for and safe.
- RDO and DON notified the Regional Maintenance Director to report to the center to make sure the windows are secure.
- Medical Director, Primary and Advanced Registered Nurse Practitioner (ARNP) notified of incident.
- Wandering risk User-Defined Assessment (UDA) was completed on all wandering/elopement risk residents.
- A Facility wide audit was conducted by DON/Designee to identify other residents who are at high risk for exit seeking and to prevent recurrence of the event.
- Signs were placed at the main exit doors to residents from exiting.
- Initiated every shift behavior management drill X 2 weeks then Bi-Weekly drills X 30 days. Monthly X 3 months. Post-test included for drills.
- In-services and competencies-initiated by the Director of Nursing/ Designee, facility-wide on prevention of Neglect and placing a resident on 1:1 observation when exit seeking is identified, regardless of the security of the unit, behavioral residents' management.
- Upon hire and as necessary, staff will complete an in-service education on neglect and the elopement system and management of behavioral residents.
- A Performance Improvement Plan was created and an Ad-hoc QAPI initiated as it relates to F600: Freedom from Abuse, Neglect and Exploitation and meeting conducted.
- Adult Protective Services (APS) was notified online.
- All newly admitted residents will continue to be screened for exit seeking behaviors on admission, quarterly, annually and as needed. The DON/Designee will audit screens weekly X 4 weeks and monthly for 2 months to ensure that all precautions measures are implemented.
- The findings of the above audits will be reported to the Quality Assurance/Performance Improvement Committee weekly until the committee determines substantial compliance has been met.
Resident Falls from Window Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide appropriate supervision to prevent a resident from falling from a second-floor window. The resident, who was admitted with a history of traumatic brain injury, major depressive disorder, and a history of falling, was severely cognitively impaired and exhibited wandering behavior. Despite these risk factors, the resident was moved to a secured second floor without continued one-to-one observation, which had been in place due to previous exit-seeking behavior. On the morning of the incident, the resident was observed wandering and attempting to exit the building, setting off an alarm at an exit door. However, the staff did not recognize these actions as exit-seeking behavior and did not reinstate one-to-one observation. The resident was last seen sitting on his bed shortly before he removed a window panel and fell approximately 20 feet to the ground, resulting in serious injuries. Interviews with staff revealed a lack of communication and documentation regarding the resident's exit-seeking behavior and the need for increased supervision. The staff on duty were not fully informed of the resident's history and risk factors, leading to inadequate monitoring and failure to prevent the accident.
Removal Plan
- Resident was assessed and 911 called to transport to hospital for higher level of care.
- Director of Nursing notified interim Administrator, Regional Director of Operations, Nurse Consultant, President of Clinical Services of incident.
- The Facility conducted a head count of residents currently residing in the facility, all were accounted for and safe.
- Regional Director of Operations and Director of Nursing notified the Regional Maintenance Director to report to the center to make sure the windows are secure.
- All windows were reinforced with extra screw to window/frame.
- Resident environment was free of accident hazards and each resident received adequate supervision and assistance devices to prevent accidents.
- Medical Director, Primary and Advanced Registered Nurse Practitioner notified of incident.
- Wandering risk User-Defined Assessment completed on all wandering/elopement risk residents.
- Signs placed at main exit doors to not let any residents exit.
- Initiated every shift elopement drills then Bi-Weekly Elopement drills. Monthly. In addition, Every shift behavior management drill then Bi-Weekly Elopement drills. Monthly post-test included for both drills.
- In-services and competencies-initiated by the Director of Nursing/ Designee, facility-wide on prevention of Resident Abuse, Neglect, elopement, resident safety, behavior management.
- Upon hire and as necessary, staff will complete this in-service education on neglect and the elopement system.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident with severe cognitive impairment who was dependent on staff for activities of daily living. The resident was admitted to the facility and later complained of knee pain during movement with a physical therapist. A progress note indicated that a Nurse Practitioner was informed of positive knee X-ray results, which showed a fracture, and the resident was sent to the hospital ER for further evaluation. However, a review of the facility's adverse and incident log did not reveal any incident report for this occurrence. During an interview, the Assistant Director of Nursing stated that the knee fracture was believed to be due to osteoporosis but could not provide documentation of such a diagnosis. Furthermore, the injury of unknown origin was not investigated as required by the facility's policy.
Failure to Conduct Required PASARR Screenings
Penalty
Summary
The facility failed to obtain a Level I Preadmission Screening and Resident Review (PASARR) for two residents, which is required for individuals with mental disorders or intellectual disabilities who need more than 30 days of care. Resident #67 was admitted post-hospitalization with diagnoses including cerebral atherosclerosis, vascular dementia, anxiety, and dysphagia. The resident's Admission Minimum Data Set (MDS) assessment indicated severe cognitive impairment, yet no PASARR was conducted. The facility's administrator confirmed the absence of a PASARR for this resident. Similarly, Resident #90, admitted with a diagnosis of psychotic disorder, also lacked evidence of a Level I PASARR prior to admission. The Assistant Director of Nursing acknowledged the absence of the required screening for this resident.
Failure to Address Resident's Discomfort in a Timely Manner
Penalty
Summary
The facility failed to address a resident's discomfort in a timely manner, as evidenced by the case of a resident who was admitted with a urinary catheter. The resident reported experiencing itching and burning sensations in her genitals, which she believed to be a yeast infection, after her catheter was changed due to a blockage. Despite informing the nurse of her symptoms and the nurse's assurance to obtain an order for an ointment, the resident did not receive any treatment for her discomfort. The resident resorted to using an antibiotic cream prescribed for her toe on her genitals for relief. There was no documentation of the catheter change, the resident's complaints, or any orders for treatment in the resident's records. The Unit Manager, unaware of the resident's concerns, did not observe any issues when discontinuing the catheter. The Desk Nurse was informed of the resident's concerns only two hours prior to the interview and was awaiting a physician's response for orders. An observation revealed the resident's genitals were reddened, inflamed, and bleeding, and the resident was resistant to relinquishing the ointment she was using for relief.
Failure to Monitor Behavior for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to provide behavior monitoring for two residents who were prescribed antipsychotic medications. Resident #105, who was admitted with diagnoses including Cerebral Atherosclerosis, Unspecified dementia, and Major Depressive Disorder, was started on Seroquel for depression. Despite the requirement for behavior monitoring due to the use of this medication, no such monitoring was documented in the resident's electronic treatment administration record (e-tar). This was confirmed during an interview with a Licensed Practical Nurse (LPN) and the facility's consultant pharmacist. Similarly, Resident #63, who was admitted with diagnoses of Psychotic Disorder and Major Depressive Disorder, was receiving antipsychotics and antidepressants. The resident's care plan indicated a risk for behavior symptoms related to these conditions. However, a review of the resident's records revealed no documentation of behavior monitoring, despite the presence of orders for medications such as Duloxetine and Pimavanserin. This lack of documentation indicates a failure to adhere to the facility's policies and procedures for monitoring residents on such medications.
Failure to Secure Resident Medications
Penalty
Summary
The facility failed to secure a resident's medications, leading to a deficiency in medication management. Resident #246, who was alert and oriented, was found to have a tube of Gentamycin ointment in her bedside drawer, which she was using inappropriately on her genitals instead of her prescribed toe. This was discovered during an interview with the resident, who admitted to using the antibiotic cream for relief of itching and burning. The Unit Manager confirmed that the resident should not have had any medications unsecured at her bedside.
Failure to Coordinate Care for Resident Requiring Specialized Equipment
Penalty
Summary
The facility failed to coordinate care for a resident requiring specialized rehabilitative services, specifically related to the use of a hoyer lift and a specialized chair. The resident, who was admitted with mild cognitive impairment and required total assistance with activities of daily living due to a laminectomy and physical limitations, had not been out of bed since admission. Despite the resident expressing a desire to get out of bed, the therapy notes did not document any reason for the resident's continued bed confinement. The Physical Therapist (PT) acknowledged the resident's need for a specialized chair and a hoyer lift for safe transfer but had not communicated this requirement to the Certified Nurse Assistant (CNA) responsible for the resident's care. Interviews revealed a lack of communication and coordination between the rehabilitation and nursing staff. The PT assumed it was the CNA's responsibility to get the resident out of bed, while the CNA stated they were only informed on the day of the interview that the resident could be transferred using a hoyer lift. The Rehabilitation Director confirmed that every resident should be out of bed unless contraindicated and noted that a recliner chair could be used temporarily. However, the Assistant Director of Nursing (ADON) had not documented any attempt to order the appropriate chair for the resident, although they claimed to be in the process of doing so.
Deficiency in Documentation of Physician Orders
Penalty
Summary
The facility failed to accurately document physician-ordered vital signs and cough secretions monitoring for a resident who was readmitted with multiple diagnoses, including hypertension and a history of falling. The resident had a BIMS score indicating moderately impaired cognitive function. Physician orders required the resident to perform cough and deep breathing exercises four times daily, with documentation of tolerance and sputum production, and to have vital signs taken every shift for three days, then daily. However, the records showed inconsistencies and omissions in documenting these orders. Vital signs were not recorded on several days, and when recorded, they lacked details about the shift. Additionally, there was a lack of documentation regarding the resident's breath sounds, sputum production, and tolerance to the exercises. Interviews with staff revealed a lack of clarity and accountability regarding the documentation process. An LPN stated that vital signs were taken by CNAs and nurses but were not consistently documented in the electronic health records. The Assistant DON was unable to explain why the documentation was incomplete or why only one RN documented in the progress notes. The facility's failure to adhere to physician orders and maintain accurate records was discussed with the Administrator and Assistant DON, highlighting a deficiency in the facility's documentation practices.
Failure to Implement CDC Infection Control Guidelines
Penalty
Summary
The facility failed to implement CDC guidelines for Contact Precautions for two residents and Enhanced Barrier Precautions for one resident. For the first resident, who had a thoracostomy and other medical conditions, a maintenance staff member entered the room without performing hand hygiene or using PPE, despite clear signage indicating Contact Precautions. The staff member was unaware of the precautions, which led to a breach in infection control protocols. For the second resident, who had hypertension and other chronic conditions, a registered nurse used a blood pressure machine that was supposed to be dedicated to the resident under Contact Precautions. However, a housekeeping staff member reported that the machine was used for another resident, indicating a failure to adhere to the guidelines for dedicated equipment. Additionally, the housekeeping staff did not consistently use PPE or perform hand hygiene as required by the Contact Precautions. The third resident, who had a history of falling and other medical issues, was supposed to be under Enhanced Barrier Precautions. A CNA assisted the resident without wearing a gown, mistakenly believing that only the resident's roommate required such precautions. This misunderstanding and lack of adherence to the guidelines resulted in another breach of infection control protocols, as the CNA's personal clothing came into contact with the resident's bed linen and wheelchair parts.
Delay in Urinalysis Results Leads to Treatment Delay
Penalty
Summary
The facility failed to obtain urinalysis results in a timely manner for a resident with a urinary tract infection (UTI), leading to a delay in treatment. The resident, who was cognitively intact and frequently incontinent of urine, was admitted to the facility and had an order for a urinalysis culture and sensitivity on December 22, 2023. However, there was no documentation indicating the reason for the urinalysis order or any signs or symptoms of the resident's condition. The urine was collected and received on December 23, 2023, but the results were not available until December 27, 2023, when a specific bacteria was identified. Consequently, the resident was prescribed an antibiotic on December 27, 2023, and received it at 5:00 PM, five days after the initial urinalysis order. An interview with the Desk Nurse revealed that preliminary results are typically available within 24 hours and should be communicated to the physician, but in this case, the preliminary report was not documented as received, and the nurse did not follow up on the urinalysis results within the expected 24-48 hours timeframe.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 246 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Boynton Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Boulevard Rehabilitation Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Heartland Nursing & Rehab Center | 2.4 mi | ★★★★★ | 1 | 0 |
| Boynton Beach Rehabilitation Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Cascades Health And Rehabilitation Center | 3.8 mi | ★★★★★ | 6 | 0 |
| Abbey Delray South | 4.2 mi | ★★★★★ | 0 | 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.