Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legacy At Boca Raton Rehabilitation And Nursing Ce during CMS and state inspections, most recent first.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet needs.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors during the review of care practices.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These deficiencies were observed during the survey and directly impacted residents requiring assistance with bowel and bladder management.
A resident did not receive safe and appropriate respiratory care when needed, as required by facility protocols.
Two residents experienced medication administration errors when LPNs failed to follow physician orders: one was not instructed to rinse her mouth after inhaled medication for COPD, and another received a medication mixed with less water than ordered due to lack of appropriate cup size. The errors were confirmed by the DON and staff, resulting in a medication error rate above the acceptable threshold.
Surveyors found that a resident did not receive appropriate care for bowel/bladder continence or incontinence, including inadequate catheter care and insufficient prevention of UTIs. These failures resulted in a deficiency related to the management of urinary and bowel needs.
A persistent foul urine-like odor was detected in the Berkshire Unit of a facility, despite cleaning efforts. The odor was noted in the hallway and inside a specific room, where a urine drainage bag with dark fluid was found under an empty bed. Staff responses varied, with some confirming the odor and others not noticing it. The Administrator acknowledged the issue and mentioned a thorough cleaning had been done, but a mild odor persisted.
A resident with no cognitive impairment and multiple diagnoses, including Ataxia and Dementia, developed a skin rash on her chest and arms, believed to be caused by wearing the same hospital gown for several days. Despite reporting the rash to CNAs, there was no documented treatment or physician order in place. Observations confirmed the rash, and the resident stated she had not received any cream. The facility's care plan and records lacked documentation of the rash, and the Unit Manager acknowledged the absence of a physician order.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, with multiple observations of unsanitary conditions, improper food temperatures, and inadequate cleaning practices. Surveyors noted issues such as uncovered soiled trays, staff with uncovered facial beards, improper thermometer sanitization, and expired food items.
The facility failed to maintain a sanitary, orderly, and comfortable environment in multiple rooms across the B, C, and D Wings. Issues included non-functional electric beds, inaccessible nurse call bells, mold, rust, disrepair of walls, algae-covered windows, and missing floor cover strips, posing potential fall hazards. These deficiencies were confirmed during an environment tour with the Assistant Administrator and Corporate Housekeeping Manager.
The facility failed to properly store residents' medications, with multiple instances of over-the-counter and prescription medications being left unsecured in residents' rooms. Additionally, wound care supply carts on the C and D wings were left unlocked and unattended, containing resident-specific treatment medications.
The facility failed to follow the approved menu for various diets, affecting numerous residents. Essential items were not prepared or served, and no substitutes were provided. A resident with multiple diagnoses did not receive physician-ordered nectar thick prune juice due to it not being reflected on the tray ticket.
The facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance for residents on special diets. Foods were prepared early and held at high temperatures until the dinner meal, negatively affecting their quality. Staff responsible for preparation was unaware of the impact of prolonged cooking and high heat holding and had not received formal training in quality food preparation standards.
The facility failed to prepare food in a proper pureed form for 10 residents with physician-ordered Pureed Diets. Observations revealed that the pureed rice had visible lumps and large pieces, and the Lunch Cook did not taste test the food for proper consistency. The surveyor requested the development of a policy to ensure proper food preparation.
A facility failed to prevent verbal abuse when a CNA was observed yelling at a resident after a trolley crash. The resident, who was cognitively intact and had multiple medical conditions, did not initially realize the yelling due to ear pain. Other staff members did not promptly assess the resident's well-being, despite recent training on abuse prevention.
A resident was found with a swollen finger and a bruise on the face, which staff failed to report and document in a timely manner. The Infection Preventionist and LPN were unaware of the bruise until pointed out by a surveyor. The resident's spouse mentioned a possible toothache but did not inform the staff earlier. The facility's documentation did not include prior notes about the bruise, leading to a delay in addressing the resident's condition and investigating the cause.
The facility failed to provide timely psychosocial assessments for a resident with disruptive behaviors, did not follow physician's orders for blood sugar monitoring for a diabetic resident, and neglected to perform timely skin assessments for a resident with a rash.
A resident with a stage 4 sacral pressure ulcer and a diabetic wound on the right heel did not receive proper wound care as per physician's orders. The Wound Care Nurse (WCN) failed to apply collagen powder and did not follow infection control protocols, such as changing gloves after cleaning wounds. Additionally, a Certified Nursing Assistant (CNA) did not wear a gown as required, and the resident was found wearing two briefs.
A facility failed to ensure proper hand hygiene and infection control during perineal and Foley catheter care for a resident. The CNA did not change gloves, sanitize hands, or change the rinse water after the resident had a bowel movement, leading to cross-contamination risks. Interviews confirmed that the facility's policies were not followed.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. The report does not specify the particular medical history or condition of the resident at the time of the deficiency, nor does it detail the specific treatment or care that was not provided as ordered.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care provided to residents requiring assistance with bowel and bladder management.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received the necessary respiratory care, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Medication Administration Errors Due to Failure to Follow Physician Orders
Penalty
Summary
The facility failed to follow physician orders for medication administration for two of four sampled residents during a medication administration observation, resulting in a medication error rate of 7.41%. For one resident with COPD and a BIMS score indicating cognitive intactness, a LPN administered inhaled medications via nebulizer but did not instruct the resident to rinse her mouth after treatment, as specifically required by the physician's order for Budesonide. The omission was confirmed by the Director of Nursing upon review of the order and observation of the medication pass. In a separate incident, another cognitively intact resident was ordered to receive Sodium Zirconium Cyclosilicate mixed with 8 ounces of water for hyperkalemia. The LPN administering the medication used a cup that only held 4 to 5 ounces, as the facility had run out of 8-ounce cups and had not yet distributed newly received stock. Multiple staff confirmed that only smaller cups were available on the medication carts at the time, and the Central Supply clerk acknowledged not considering alternative sources for the correct cup size. The DON verified that the medication was not mixed according to the physician's order.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the cited deficiency.
Persistent Urine Odor in Berkshire Unit
Penalty
Summary
The facility failed to maintain a clean environment free of offensive odors in the Berkshire Unit, as evidenced by a persistent foul urine-like odor. During a tour of the unit, a strong urine odor was detected in the hallway between specific rooms and inside one of the rooms. Despite cleaning efforts by a housekeeper, the odor persisted. The housekeeper, who required translation assistance, confirmed the presence of urine in the bathroom of the affected room. The Housekeeping Director also confirmed the strong odor during a side-by-side observation. Further investigation revealed a urine drainage bag with a small amount of dark fluid under an empty bed in the room, which was picked up by the District Housekeeping Manager. Interviews with staff members provided mixed responses, with one LPN not noticing the odor and another confirming its presence in the hallway. The facility's Administrator acknowledged awareness of the odor issue and mentioned that a thorough cleaning had been conducted, although a mild odor remained later in the day.
Failure to Identify and Treat Resident's Skin Rash
Penalty
Summary
The facility failed to identify and treat a resident's skin redness/rash, which was observed on the resident's chest, right upper arm, and left upper arm, with no documented treatment in place. The resident, who had diagnoses including Ataxia, Dementia, Anxiety Disorder, Chronic Kidney Disease, and foot pain, was admitted to the facility with no cognition impairment. The resident required supervision or assistance for daily activities, including personal hygiene and dressing. During an interview, the resident revealed wearing the same hospital gown for 2-3 days due to a lack of gowns, which she believed might have caused the rash. The resident reported the rash to CNAs but was unsure if the nurse was informed. Observations confirmed the redness and itching, and the resident stated she had not received any cream for the rash. The resident's active care plan, medication, and treatment administration records lacked documentation related to the skin redness/rash. There was no physician order or nursing progress notes addressing the issue. Staff interviews revealed that the CNAs were aware of the rash and had informed the nurse, but the nurse did not notice the rash during a previous shift. The Unit Manager confirmed the absence of a physician order and stated she would contact the physician for an order after observing the rash. The Director of Nursing was informed of the findings during the survey.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During multiple tours, surveyors observed numerous deficiencies, including uncovered soiled resident food trays, staff with uncovered facial beards, improper sanitization of digital food thermometers, and deeply grooved cutting boards with black mold. Additionally, juices and cottage cheese were not held at the required temperatures, and food transportation carts were heavily soiled. The Victory reach-in refrigerator was found to be in disrepair, rust-laden, and lacking an operational thermometer. Shelving and juice dispensing equipment were also noted to be unsanitary, and commercial can openers and blenders were found with dried food matter and stagnant water, respectively. The dish machine and various food preparation surfaces were not properly cleaned, and expired food items were found in the walk-in refrigerator and freezer, including non-pasteurized raw eggs with black mold, expired cottage cheese, Greek yogurt, and prepared foods. Further observations revealed that the facility's chemical testing of cleaning cloth buckets and 3-compartment sinks did not meet regulatory requirements for sanitizing chemicals. During meal observations, hot and cold foods were not held at the required temperatures, and staff repeatedly failed to properly sanitize thermometers between food items. Specific temperature violations included baked eggs, orange juice, milk, ground beef brisket, chopped chicken tenders, California blend vegetables, apple pie, gefilte fish plates, diced turkey plates, sliced turkey plates, tuna fish plates, buttered noodles, and pureed meatballs. Surveyors had to intervene multiple times to prevent the serving of improperly held foods. The facility's food service director and staff demonstrated a lack of adherence to food safety protocols, including the improper use of cleaning and sanitizing materials, failure to maintain appropriate food temperatures, and inadequate cleaning of food preparation and storage areas. These deficiencies were observed over several days and involved multiple staff members, indicating systemic issues within the facility's food service operations.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment in multiple rooms across the B, C, and D Wings. Specific deficiencies included an electric bed in the B Wing that was not working, preventing staff from positioning a resident for assistance with feeding. In the C Wing, several rooms had issues such as nurse call bell cords being wrapped around bed frames, making them inaccessible to residents, large black mold areas on bathroom ceiling tiles, dust-laden O-2 concentrator filters, rusted portable toilet commode seats, heavily rusted bed frames, and disrepair of bathroom and room walls. Additionally, room windows were covered in green algae, and personal hygiene items were improperly stored on top of paper towel dispensers. A bed rail was also found unattached and on the floor in one room. Hallway entry floor cover strips were missing in multiple rooms, posing potential fall hazards. In the D Wing, a nurse call light was wrapped around a bed frame, making it unreachable for the resident. These findings were observed during initial resident/room screenings and an environment tour conducted by the facility's Assistant Administrator and Corporate Housekeeping Manager. The issues were confirmed and discussed with the facility's administration, highlighting a significant lapse in maintaining a safe, clean, and comfortable environment for residents. The deficiencies were noted in specific rooms and common areas, indicating a widespread problem across multiple wings of the facility.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure that residents' medications were properly stored, as evidenced by multiple instances of over-the-counter and prescription medications being left in residents' rooms. For example, Resident #119 had an Aspercreme-Lidocaine roll-on bottle on her table, which she brought from home without the nurses' knowledge. Similarly, Resident #473 had a bottle of Clear-Lax powder on his table, despite being on a different prescribed laxative. Both residents lacked physician orders for self-administration and corresponding assessments or care plans in their clinical records. Additionally, Resident #474 had a white pill and a TUMS bottle with another person's name on it, which were not prescribed to him and were left unsecured in his room. Resident #475 had a bottle of 8-Hour Arthritis Pain Acetaminophen on her table, which was brought by a neighbor and left unsecured, posing a risk to her confused roommate. Resident #476 had Dry Eye Relief lubricant and Azelastine Hydrochloride nasal spray on her window sill, without physician orders or self-administration assessments in her records. These instances indicate a systemic failure to adhere to medication storage policies and procedures, as well as a lack of proper documentation and assessment for self-administration of medications. Furthermore, Resident #129 had four different prescription medications left unattended in a medication cup on her bedside table for over seventeen hours. The medications were not removed until after surveyor intervention, and there was no self-administration assessment in her records. Additionally, the facility failed to secure wound care supply carts on the C and D wings, which contained resident-specific treatment medications and other supplies. These carts were left unlocked and unattended, accessible to staff, residents, and visitors. The facility's policy on medication labeling and storage was not followed, and staff members acknowledged the deficiencies when interviewed by surveyors.
Failure to Follow Approved Menu and Dietary Orders
Penalty
Summary
The facility failed to follow the approved menu for various diets, including Regular Diets, Mechanical Altered Chopped Diets, Mechanical Altered Ground Diets, and Pureed Diets, affecting a significant number of residents. During observations on 04/07/24 and 04/08/24, it was noted that essential items such as dinner rolls and [NAME] bread were not prepared or served, and no substitutes were provided. Interviews with the lunch cook revealed that the approved menu was not available, leading to incorrect meal preparation and service. Additionally, the facility's diet census confirmed the number of residents affected by these dietary lapses. Resident #7, who has multiple diagnoses including Alzheimer's Disease, Dysphagia, and Diabetes Mellitus, did not receive the physician-ordered nectar thick prune juice during breakfast on 04/08/24. Staff interviews confirmed that the prune juice order was not reflected on the tray ticket, resulting in the resident not receiving it. The Dietary Supervisor acknowledged that if an item is not on the tray ticket, it would not be served to the resident, indicating a systemic issue in meal preparation and service documentation.
Deficiency in Food Preparation for Special Diets
Penalty
Summary
The facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance for residents on physician-ordered pureed, mechanically altered chopped, and mechanically altered ground diets. During an initial kitchen/food service observation tour, it was noted that foods were being prepared early in the day and held at high temperatures until the dinner meal. Specifically, approximately 40 pounds of green beans were observed boiling and breaking apart from overcooking, and a full steam table-sized pan of baked vegetarian ziti and vegetable burgers were fully cooked and held in the oven at high temperatures from 10 AM until the 4:30 PM dinner tray line start time. Staff B, responsible for the preparation, stated that the foods are cooked early to be able to puree, chop, and ground them for mechanically altered diets and was unaware that prolonged cooking and high heat holding would negatively affect the foods' nutritive value, appearance, and palatability. Staff B also mentioned not having received formal training by the facility for quality food preparation standards. A review of the facility's diet census revealed that 10 residents had physician-ordered pureed diets, 24 residents had physician-ordered mechanically altered chopped diets, and 3 residents had physician-ordered mechanically altered ground diets. The deficiency was identified through observation, interview, and record review, indicating a systemic issue in the facility's food preparation process that affected the quality of meals provided to residents with specific dietary needs.
Failure to Prepare Proper Pureed Food
Penalty
Summary
The facility failed to prepare food in a proper pureed form to meet the needs of 10 residents with physician-ordered Pureed Diets. During an observation of the lunch meal in the main kitchen, the surveyor noted that the pureed rice had visible lumps and large pieces of rice, which did not meet the required smooth, homogenous, and pudding-like texture. A taste test conducted by the surveyor and the Food Service Director confirmed the presence of large lumps and pieces of rice in the pureed mixture. The surveyor requested that the pureed rice mixture not be served to residents on pureed diets and to puree the rice until the proper consistency was achieved. An interview with the Lunch Cook revealed that she did not taste test pureed food for proper consistency and was unaware of the risks of choking or aspiration for residents with swallowing deficiencies and dysphagia. The facility's Diet Census indicated that there were 10 residents with physician-ordered Pureed Diets, including two sampled residents. The surveyor requested that the Food Service Director and the facility's Registered Dietitian develop a policy to ensure that foods are properly prepared for all meals.
Failure to Prevent Verbal Abuse
Penalty
Summary
The facility failed to prevent verbal abuse towards a resident by a staff member. The incident involved a Certified Nursing Assistant (CNA) who was observed yelling at a resident after a trolley containing used wares crashed. The CNA accused the resident of intentionally rolling in front of the trolley. The resident, who was cognitively intact and had a history of multiple medical conditions, did not initially realize the CNA was yelling due to ear pain and ringing from the crash. The resident later confirmed that the trolley had run into him and that he had not moved intentionally. Interviews with other staff members revealed that they were aware of the crash but did not immediately check on the resident's well-being. A Licensed Practical Nurse (LPN) and a Registered Nurse (RN) both admitted to hearing the crash and seeing the aftermath but did not promptly assess the resident. The LPN consoled the resident only after the surveyor had checked on him, while the RN was preoccupied with medication and did not perform an immediate assessment. The facility's policy on abuse prevention and response was reviewed, indicating that verbal abuse includes yelling or hovering over a resident with the intent to intimidate. Despite an in-service training on abuse recognition and response conducted shortly before the incident, the staff's actions demonstrated a failure to adhere to these guidelines. The incident highlights a lapse in the facility's efforts to prevent and address verbal abuse, as well as a lack of immediate and appropriate response to potential harm to the resident.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in a timely manner for a resident reviewed for skin discoloration. During an observation, the resident was found yelling and crying out about hand pain, with a swollen right ring finger and a red purplish area on the left side of the mouth. The Infection Preventionist initially did not notice the bruise on the resident's face and only became aware after the surveyor pointed it out. The CNA reported the redness on the resident's back but did not mention the bruise on the face, and the LPN assigned to the resident was also unaware of the bruise until it was pointed out by the surveyor. The resident was unable to recall what happened, and the spouse mentioned a possible toothache but did not inform the staff earlier. The facility's documentation did not include any prior notes about the bruise on the resident's face before the surveyor's observation. The incident was not reported to the proper authorities in a timely manner, as the staff failed to document and communicate the bruise on the resident's face promptly. The Infection Preventionist and the Director of Nursing conducted assessments and contacted risk management, the police, and social services only after the surveyor's intervention. The resident's spouse was also informed later, and it was noted that the resident is on anticoagulant medication, which could cause easy bruising. The lack of timely reporting and documentation of the injury led to a delay in addressing the resident's condition and investigating the cause of the bruise.
Failure to Provide Timely Assessments and Follow Physician Orders
Penalty
Summary
The facility failed to provide timely psychosocial assessments for a resident with disruptive yelling behaviors. Resident #104, who has severe cognitive impairment and a history of depression and dementia, exhibited frequent yelling and combative behavior. Despite the care plan's interventions to address these behaviors, staff did not effectively manage or assess the resident's needs, leading to ongoing disturbances for other residents. Interviews with staff and other residents confirmed the disruptive nature of Resident #104's behavior and the lack of effective intervention from the facility's staff. The facility also failed to follow physician's orders regarding blood sugar monitoring for Resident #323, who has Type 2 Diabetes Mellitus. The resident experienced multiple instances of blood glucose readings over 400, which were not reported to the physician as required. This oversight was confirmed through interviews with staff and a review of the resident's medical records, which showed no documentation of physician notification for the high blood sugar levels. Additionally, the facility did not perform timely skin assessments for Resident #71, who complained of buttock pain. Despite the resident's complaints and visible signs of a rash, staff did not promptly assess or report the condition to the physician. Observations and interviews revealed that the resident had a fungal rash that required medical attention, which was not addressed in a timely manner by the facility's staff.
Failure to Provide Proper Wound Care and Follow Infection Control Protocols
Penalty
Summary
The facility failed to ensure that a resident received wound care consistent with professional standards of practice. Resident #30, who had multiple diagnoses including a stage 4 sacral pressure ulcer and a diabetic wound on the right heel, did not receive proper wound care as per the physician's orders. The physician's order to cleanse the sacral wound with normal saline solution and apply collagen powder and calcium alginate was discontinued in error by the Wound Care Nurse (WCN) on 03/05/24. This error led to the omission of collagen powder during wound care observations on 04/09/24, despite the Wound Care Specialist's (WCS) plan indicating its necessity for the treatment of the sacral wound. During wound care observations, the WCN did not follow proper infection control protocols. The WCN failed to change gloves after cleaning the wounds before applying new dressings, which is a critical step in preventing infection. Additionally, the Certified Nursing Assistant (CNA) assisting with the care did not wear a gown as required, and the resident was found to be wearing two briefs, which is not standard practice. The WCN also did not address a fungal rash observed on the resident's bottom and buttocks during the wound care session. Interviews with the staff revealed a lack of awareness and adherence to the care plan and wound care protocols. The Director of Nursing (DON) acknowledged that the WCN missed a step by not changing gloves after cleaning the wound. The WCN admitted to discontinuing the physician's order in error and not applying the collagen powder during the wound care observation. The WCS confirmed that the treatment plan included the application of collagen powder and calcium alginate, which was not followed during the observed wound care session.
Inadequate Hand Hygiene and Infection Control During Perineal and Foley Catheter Care
Penalty
Summary
The facility failed to ensure appropriate hand hygiene, care, and cleanliness to avoid cross-contamination during perineal and Foley catheter care for a resident. The deficiency was observed during a care procedure for a resident with multiple diagnoses, including dementia and neuromuscular dysfunction of the bladder. The resident was noted to have a bowel movement during the procedure, but the CNA did not change gloves, sanitize hands, or change the rinse water after cleaning the feces before continuing with the perineal and Foley catheter care. The CNA, assisted by another CNA, initially washed their hands before beginning the care. However, the CNA did not allow the resident to test the water temperature and proceeded with the care without changing gloves or the rinse water after the resident had a bowel movement. The CNA continued to clean the resident's perineal area and Foley catheter tubing with the same gloves and water, only changing gloves and sanitizing hands before drying the resident's perineal area. Interviews with the CNA, a Registered Nurse/Unit Manager, and the Director of Nursing confirmed that the CNA should have changed gloves, sanitized hands, and changed the rinse water after the resident had a bowel movement. The facility's policies on perineal care and infection control were not followed, leading to the observed deficiency in care for the resident.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 253 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Boca Raton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowbrooke Court At St Andrews Estates | 0.5 mi | ★★★★★ | 0 | 0 |
| Encore At Boca Raton Rehabilitation And Nursing Ce | 1 mi | ★★★★★ | 0 | 0 |
| Boca Circle Rehabilitation Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Stratford Court Of Boca Raton | 2.1 mi | ★★★★★ | 10 | 0 |
| Avante At Boca Raton, Inc. | 2.2 mi | ★★★★★ | 16 | 0 |
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