Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Palm Beach Nursing Center during CMS and state inspections, most recent first.
Housekeeping and maintenance services failed to keep multiple resident rooms and common areas clean and sanitary. Surveyors observed separating floor tiles, nonworking sinks, stained ceilings, damaged walls and doors, chipped furniture, dust and debris in AC units, and unsecured face plates leaving holes in walls. A cognitively intact resident reported having to reach into the commode tank and pull the chain attached to the plunger to flush the toilet for about a week.
Unsafe food handling and unsanitary kitchen conditions were observed in the dietary area. A Dietary Aide handled dirty and potentially contaminated wares with gloved hands and then handled cleaned and sanitized wares with the same gloves, while the kitchen also had residue on equipment, debris on shelves and behind equipment, damaged wall and window surfaces, rust on a vent, and ice buildup in the freezer. On a follow-up visit, frozen mixed vegetables were being thawed on top of a convection oven at ambient room temperature, which the CDM acknowledged was not a safe thawing method.
Failure to Maintain Equipment, Call Light, and Resident Items Within Reach: A resident with multiple chronic conditions reported a low airloss mattress that tilted and was never repaired after being checked by maintenance, despite the bed being rented and needing periodic reinspection. Staff also left one resident’s call light out of reach even though the care plan required it to be accessible, and another resident with stroke-related left-sided weakness repeatedly had the call light, positioning remote, and bedside table placed on the affected side.
A resident with COPD, emphysema, anxiety, and dementia had an MDS Significant Change assessment showing intact cognition and Hospice services, along with a physician order for Hospice and a signed DNR. However, a late Social Services assessment did not reflect Hospice status and incorrectly listed the resident as Full Code. Staff interviews confirmed the assessment was completed after the ARD and that the discrepancies were mistakes.
Delayed PRN Pain Medication Administration: A resident with a left arm fracture and multiple spinal fractures reported repeated delays in receiving PRN oxycodone-acetaminophen for voiced pain. The resident said staff sometimes cited shift change or not having the keys, and she tracked the times herself because doses were delayed by hours, including overnight. The ADON reviewed the MAR/TAR and agreed the medication should have been given timely when the resident reported pain.
The facility failed to accurately document narcotic administration and waste for three residents. During cart reviews, an RN removed Oxycodone and Tramadol from locked narcotic storage, but the MAR and narcotic sheets had missing entries, an incomplete waste record without a date or time, and a dosing discrepancy where one Oxycodone dose was given earlier than ordered. The DON agreed some documentation was incomplete, and staff could not confirm who co-signed the waste or when it occurred.
A nurse administered gabapentin to a resident with Parkinsonism and moderate cognitive impairment using medication cards that had no resident name and did not match the current order. The card directions differed from the resident’s prescribed dose, and the nurse initially dispensed the medication before realizing the packages were not for that resident.
Approved dessert recipes and meal tickets were not followed for lunch service. Residents were served desserts that did not match the menu or recipe, including pudding served instead of the documented parfait and a yellow cake with frosting and chocolate syrup served instead of marble cake. A resident with DM, HTN, HLD, CKD, and chronic ulcers stated dietary staff were not following the meal tickets, and the CDM acknowledged the desserts served were not the correct items.
Food allergies and meal preferences were not followed for two residents. One resident with severe cognitive impairment had a documented gluten allergy/intolerance, yet was served items containing flour, including pot pie, noodles, and meatballs, and the CDM stated there were no gluten-free items available. Another resident with intact cognition reported dietary staff were not following meal tickets, and during observation was served Swedish meatballs and chocolate pudding instead of the items listed on the tray ticket.
A resident with diabetes, a left foot ulcer, and a recent amputation did not receive timely podiatrist-ordered care due to missed transportation for a follow-up appointment and failure to update wound care orders in the medical record. Staff interviews revealed inconsistent processes for reviewing and implementing new orders after outside appointments, leading to delays in necessary treatment.
The facility failed to maintain resident privacy, with incidents including a resident left exposed during care due to inadequate curtain coverage, staff entering rooms without permission, and loud discussions of medical information in hallways. These actions affected residents' privacy and confidentiality, causing stress and discomfort.
The facility failed to provide adequate staffing, leading to care deficiencies such as delayed incontinence care and unresponsive staff, particularly during night shifts and weekends. Residents reported long wait times for assistance and cold food service, with staffing levels notably lower on weekends.
A resident with cognitive impairment and on medications for insomnia, depression, and anxiety voiced concerns about her roommate's disruptive behavior, but the facility failed to document or address the grievance. The Social Services Assistant acknowledged the complaint but did not inform the Social Services Director, resulting in no follow-up or resolution.
The facility failed to ensure timely, accurate, and complete PASSAR documentation for three residents with mental disorders or intellectual disabilities. One resident's PASSAR was missing, another's was incomplete with no Level II PASSAR despite indications, and a third had several sections left blank. The Social Services Director acknowledged issues with incomplete PASSARs from the hospital and later provided completed forms.
The facility failed to follow physician orders for two residents regarding blood pressure parameters and vital sign documentation, and did not provide prescribed medication to a resident with heart failure and COPD. One resident received Midodrine despite high blood pressure, and another had incomplete vital sign records. A third resident reported not receiving Bumetanide, affecting his breathing and causing swelling, despite the MAR indicating administration. The DON confirmed the medication was missing.
A resident who underwent cataract surgery did not receive her prescribed eyeglasses, resulting in her inability to read. Despite being aware of the issue, the facility failed to track or document the missing eyeglasses effectively. Substitute glasses provided were ineffective, and the facility's policy lacked a process for handling such situations, leading to a prolonged delay in resolving the issue.
A resident with a history of UTIs received improper incontinence care, as observed when a CNA cleaned the resident's back side incorrectly, causing discomfort. The resident's medical records showed a recent UTI and uncompleted urinalysis orders. The resident's son noted frequent UTIs at the facility, and a rash was observed during care. The CNA admitted to not following the correct procedure, and the Unit Manager was unaware of the resident's condition.
The facility failed to provide adequate respiratory care for four residents, with issues including dirty oxygen equipment, misplaced nasal cannulas, missing Ambu bags, and failure to change oxygen tubing and humidifiers as ordered. These deficiencies indicate lapses in staff adherence to care protocols and physician orders, potentially compromising resident safety.
Two medication administration errors were identified, resulting in a 7.69% error rate. An LPN administered incorrect doses to two residents: one received fewer Methocarbamol tablets than prescribed, and another received Losartan prematurely due to a MAR discrepancy.
The facility failed to obtain and document laboratory services for two residents, resulting in deficiencies. One resident, who was cognitively impaired and incontinent, had three unfulfilled urinalysis orders with no follow-up actions. Another resident's blood work was marked as completed, but no results were documented. The facility's staff did not provide further information despite being informed of the issues.
The facility failed to serve meals at palatable temperatures, as reported by several residents who experienced cold meals. Cognitively intact residents noted that food trays often sat in carts before distribution, leading to inconsistent meal temperatures. Grievance logs confirmed multiple complaints about cold food over the past six months.
The facility failed to accommodate dietary preferences and needs for several residents, leading to dissatisfaction and potential health concerns. A diabetic resident was served inappropriate foods, a vegetarian received meals with meat, and residents requiring double portions or specific preferences were not consistently accommodated. The dietary management process was inadequate, with residents not receiving menus to select their choices and meal tickets not accurately reflecting preferences.
A facility failed to follow infection control practices during a blood sugar check and did not properly implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter and pressure injuries. An LPN used non-disinfecting wipes on a glucometer, and a CNA did not wear a protective gown during high-contact care activities, compromising infection control measures. Staff interviews revealed a lack of awareness about the necessity of gowns as part of PPE for EBP.
The facility failed to ensure a clean and homelike environment, with issues such as damaged furniture, stained curtains, and persistent urine odor across three units. Interviews revealed communication gaps and unclear responsibilities among staff regarding maintenance and cleanliness.
A facility failed to provide adequate ADL care for three residents, leading to deficiencies in incontinence care, personal hygiene, and grooming. One resident with hemiplegia was left in soiled briefs for extended periods, resulting in skin redness. Another resident reported not having his hair shampooed for six months and infrequent perineal care. A third resident with cognitive impairment had dirty fingernails despite needing assistance. Staff were slow to respond to care needs, and personal hygiene was neglected.
Housekeeping and Maintenance Deficiencies in Resident Rooms and Common Areas
Penalty
Summary
The facility failed to provide housekeeping and maintenance services in a manner that maintained a clean and sanitary environment in 20 of 62 rooms and in common areas of the facility. During an environmental tour on 01/08/26 with the Maintenance Director and Maintenance Assistant from a sister facility, surveyors observed multiple room and common-area deficiencies, including separating floor tiles, nonworking hand-washing sinks, stained ceilings, damaged and unpainted walls, chipped doors, missing rubber edging on overbed tables exposing particle board, cracked or unsecured face plates leaving holes in walls, dust and debris inside wall-mounted air conditioning units, and stained ceiling tiles. In one room, the resident stated on 01/06/26 that she had to reach into the commode tank and pull the chain attached to the plunger to flush the toilet for about the last week; the resident had a BIMS score of 14 and was cognitively intact.
Unsafe food handling and unsanitary kitchen conditions
Penalty
Summary
Food was not prepared, stored, distributed, and served in accordance with professional food safety standards. During the initial kitchen tour, the hand washing sink was not secured to the wall, the exterior of the mechanical dishwashing machine had residue, cleaned and sanitized trays were wet nesting on a shelf in the dishwashing area, and a Dietary Aide was observed handling dirty and potentially contaminated wares with gloved hands and then handling cleaned and sanitized wares with the same gloves until the surveyor intervened and instructed the aide to remove the gloves and perform hand hygiene. Additional observations included a chipped painted surface on the interior door of the ice machine, residue and debris on the shelf under the hot holding unit, debris behind the plate warmer, damaged and peeling wall surfaces behind the cooking equipment, a chipped and damaged wall and window frame between the walk-in cooler and processing area, rust on an air conditioning vent over the processing area, and ice accumulation from the cooling unit in the walk-in freezer. During a follow-up kitchen visit, a full-sized six-inch-deep hotel pan containing bags of frozen mixed vegetables was observed on top of the convection oven. When asked, Staff G stated the vegetables were frozen and were being thawed. The CDM acknowledged that placing foods at ambient room temperature was not a safe method for thawing food.
Failure to Maintain Equipment, Call Light, and Resident Items Within Reach
Penalty
Summary
The facility failed to reasonably accommodate resident needs and preferences by not addressing a malfunctioning bed in a timely manner for a resident with acute osteomyelitis, diabetes, hypertension, hyperlipidemia, chronic kidney disease, chronic embolism and thrombosis of the lower extremity, and non-pressure chronic ulcers. The resident, who had a BIMS score of 14 and intact cognition, reported that the low airloss mattress did not have enough air and tilted to one side. He stated he had reported the problem to nursing staff in the middle of September and maintenance had checked it, but no one returned to repair it. The bed had a rental sticker with company information and a reinspection due date, and the resident was later observed lying toward the left side of the bed. The resident’s bed was reviewed with the Interim Maintenance Director, who stated the resident preferred to lie on the left side because the overbed table was on the right side and that the resident’s size caused the bed to deflate on that side. The resident disagreed and stated he had tried lying on the other side and the bed still leaned or tilted. A company supervisor later confirmed the bed was rent-to-own, that annual reinspection was recommended to keep it in good working order, and that no service requests had been placed for the equipment. The resident was then observed in a new bed and stated it was better inflated and even. The facility also failed to keep a call light within reach for a resident with encephalopathy, COPD, depression, CHF, hypertension, and BPH, whose BIMS score was 09 and who was visually impaired. Although the care plan directed staff to ensure the call light was within reach, the resident’s call light was observed hanging on the wall panel and not accessible while he was in bed. Staff responded when the surveyor activated the call light, repositioned the resident, and left the call light hanging on the wall panel. A nurse later confirmed the call light was not within the resident’s reach. In addition, the facility failed to keep another resident’s items accessible; that resident had hemiplegia and hemiparesis following cerebral infarction, a BIMS score of 06, and left-sided weakness, yet the call light, positioning remote, and bedside table were repeatedly observed on the resident’s affected left side.
Failure to Accurately Assess Hospice and Code Status
Penalty
Summary
The facility failed to assess a resident accurately and in a timely manner for a change in status. Resident #5 had diagnoses including COPD, emphysema, muscle wasting and atrophy, anxiety, and dementia, and the most recent MDS Significant Change assessment dated 11/10/25 showed a BIMS score of 13, indicating intact cognition, and also indicated the resident was receiving Hospice services. The record also contained a physician order showing the resident was admitted to Hospice on 11/03/25 and a DNR form signed by the resident on 11/04/25. A quarterly Social Services assessment, entered as a late entry and created on 12/17/2025 with an effective date of 11/26/2025, did not indicate that the resident was under Hospice services and stated that the resident was to remain Full Code. During interviews, the Regional MDS Nurse Coordinator stated the Social Worker's assessments had to be completed by the ARD, and the Social Services Director stated assessments were completed before each ARD date. The Social Services Director could not explain why Resident #5's assessment was created more than a month after the ARD, and the Social Services Director's Assistant stated the discrepancies in the assessment were all mistakes.
Delayed PRN Pain Medication Administration
Penalty
Summary
The facility failed to timely administer PRN pain medication to a resident who was voicing pain. Resident #139 was admitted with a displaced fracture of the left olecranon process and multiple fractures of the neck and back, and the MDS documented a BIMS score of 15, indicating the resident was cognitively intact. The care plan identified the resident as at risk for pain related to the fractures and directed staff to anticipate the need for pain relief, respond immediately to complaints of pain, and monitor and report pain episodes. The resident had an active order for oxycodone-acetaminophen 10-325 mg, 1 tablet by mouth every 4 hours as needed for pain. Review of the January MAR/TAR showed multiple PRN administrations documented for pain levels ranging from 5 to 9, with gaps between doses that the resident described as lasting from a couple of hours up to 12 hours. During interview, the resident stated staff sometimes said they did not have the keys yet or that it was too early, especially during shift change, and that she had begun tracking the times herself because of the delays. The ADON reviewed the MAR/TAR with the surveyor and agreed the medication should have been administered timely when the resident was voicing pain.
Incomplete Narcotic Documentation and Medication Record Discrepancies
Penalty
Summary
The facility failed to accurately document narcotic medications dispensed, administered, or disposed of for three sampled residents. During a medication storage review of the North Cart, Staff B, RN removed Oxycodone 5-325 mg for one resident and Oxycodone 10 mg for another resident from the locked narcotic box, and the controlled medication utilization records matched the remaining pill counts. However, a side-by-side review of the narcotic sheet and electronic MAR showed no electronic entries for two Oxycodone removals for one resident, and the MAR for another resident showed the medication could be given three times per day as needed while the pill pack order stated every 8 hours as needed. The MAR timestamp review also showed one dose was administered 6 hours after the prior dose instead of after 8 hours. During a second medication storage review of the South Cart, Staff C, RN removed Tramadol HCL 50 mg for another resident and the remaining pill count matched the controlled medication utilization record. However, the narcotic sheet entry on line 5 was incomplete because it lacked a date and time, although it documented an amount given of one and had initials in the error column. The DON agreed the entry was incomplete and could not confirm whether the signatures on the narcotic waste/spillage section matched the initials on the incomplete line. Staff D and Staff L later stated the pill had been loose or open and was wasted with another nurse, but neither could remember who co-signed the waste or when it occurred.
Unlabeled Gabapentin Medication Cards Used During Administration
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles when a medication administration observation was conducted for a resident with Parkinsonism and moderate cognitive impairment. The resident had an order for Gabapentin 100 mg orally three times daily for diabetic neuropathic pain, but the medication card presented by the nurse was missing the resident’s name and appeared to have been ripped off. The card also read Gabapentin 100 mg, 3 capsules (300 mg) by mouth twice daily for neuropathy, which did not match the resident’s current order. During the observation, the nurse initially dispensed one capsule, then after reviewing the card and additional medication packages for the resident, identified that the packages lacked resident names and did not belong to the resident. The nurse then counted the medication in the cup, found a discrepancy between the number of pills dispensed and the medication card directions, and added two extra capsules after realizing the mismatch. The DON later agreed with the findings during the side-by-side review and stated the medication cards would be sent back to pharmacy to be labeled appropriately.
Failure to Follow Approved Dessert Recipes and Meal Tickets
Penalty
Summary
Menus were not followed as approved, and the facility served desserts that did not match the approved recipes or the tray tickets. On 01/06/26, the approved menu called for a Cinnamon [NAME] Sugar Blondie for lunch dessert, but during the meal observation many residents, including Residents #3, #120, #122, and #163, were served what appeared to be chocolate pudding. Their tray tickets documented "Vanilla Pudding Parfait." The approved recipe for Fortified Pudding Parfait allowed any flavor of pudding and required whipped topping as garnish, but the Certified Dietary Manager acknowledged that the pudding served was not the correct Vanilla Pudding Parfait because it was not vanilla and did not have garnish. On 01/07/26, the approved lunch menu called for Marble Cake with [NAME] Frosting, and the recipe required combining chocolate and white cake batters to create swirls before baking and frosting the cooled cake. During the kitchen tour, staff had prepared what appeared to be a yellow cake with a dollop of white frosting and a swirl of chocolate syrup on top. The Certified Dietary Manager stated the details of the marble cake recipe and acknowledged that the cake being served was not a marble cake and that the yellow cake and the marble cake had entirely different flavors. Record review for Resident #3 showed diagnoses including acute osteomyelitis, diabetes, hypertension, hyperlipidemia, chronic kidney disease, chronic embolism and thrombosis of the lower extremity, and non-pressure chronic ulcers. The resident had a BIMS score of 14 and a diet order for a controlled carbohydrate, no added salt diet with regular texture and thin liquids. Resident #3 stated dietary staff were not following what was on the meal tickets, and during a meal observation the resident’s tray ticket specified Vanilla Pudding Parfait but the resident had chocolate pudding.
Food Allergies and Meal Preferences Not Followed
Penalty
Summary
The facility failed to provide food that avoided allergens for Resident #103. The resident was readmitted with multiple diagnoses including cerebral infarction, dementia, psychotic disturbance, mood disturbance, anxiety, seizures, depression, hypertension, and hypothyroidism, and the annual MDS documented a BIMS score of 02, indicating severe cognitive impairment. The medical certification and diet history documented a gluten allergy/intolerance, with the diet history noting “GLUTEN no bread.” During dining observations, the resident’s tray ticket identified allergies as flour, yet the resident was served Chicken Pot Pie, and later was served Egg Noodles and Ground Swedish Meatballs. The CDM provided ingredients for the meatballs and noodles and both contained flour, and the pot pie filling recipe also contained flour. The CDM stated there were no gluten free items available. The facility also failed to provide food according to Resident #3’s preferences. Resident #3 had diagnoses including acute osteomyelitis, diabetes, hypertension, hyperlipidemia, chronic kidney disease, chronic embolism and thrombosis of the lower extremity, and non-pressure chronic ulcers, and the quarterly MDS documented a BIMS score of 14, indicating intact cognition. The physician diet order was CCD, NAS, regular texture, regular/thin liquids. During interview, the resident stated dietary staff were not following what was on the meal tickets. During a meal observation, the tray ticket specified Vanilla Pudding Parfait and Lemon Butter Baked Fish Fillet, but the resident was served Swedish Meat Balls and Chocolate Pudding. The resident stated he did not care for the meatballs and declined asking for another food item.
Failure to Coordinate and Implement Podiatrist-Ordered Care
Penalty
Summary
A deficiency occurred when the facility failed to coordinate and implement care as ordered by a podiatrist for a resident with a complex medical history, including Type 2 diabetes, a left foot ulcer, chronic osteomyelitis, and a right below-knee amputation. The resident was scheduled for a follow-up podiatry appointment for surgical debridement, but missed the appointment because nursing staff did not arrange transportation. Additionally, the facility did not ensure that updated wound care orders from the podiatrist were entered into the resident's record, and there was a lack of documentation of podiatry visit notes in the resident's chart. Interviews with facility staff revealed that neither the Unit Manager nor the Assistant Director of Nursing were aware of new orders or scripts for medical clearance and antibiotics provided by the podiatrist. The process for reviewing and implementing new orders after outside appointments was inconsistently followed, resulting in the resident not receiving timely care as ordered. The resident's daughter expressed concern about the delay in care and the lack of coordination for necessary medical follow-up.
Privacy Violations in Resident Care and Information Disclosure
Penalty
Summary
The facility failed to ensure the privacy of residents' personal and medical records, affecting several residents. Resident #9, who was cognitively intact, expressed significant stress due to privacy violations during care. He reported that staff often did not close privacy curtains fully during personal care, leaving him exposed. Additionally, staff entered his room without knocking or waiting for permission, exacerbating his stress. During an interview with Resident #9, a CNA entered the room without knocking, further demonstrating the lack of privacy. The resident also expressed concern about his roommate's visitors potentially seeing him exposed due to inadequate curtain coverage. Another incident involved staff discussing a resident's HIV medication loudly in the hallway, where other staff and potentially residents could overhear. This breach of confidentiality was acknowledged by the unit manager present at the time. Such actions compromise the privacy of residents' medical information, which is a critical aspect of their rights. Resident #77 was found lying naked on his bed with the door open and the privacy curtain not drawn, while the CNA attending to him left the room. The resident indicated that sometimes staff did not pull the curtain for privacy, although he seemed resigned to this lack of privacy. These incidents collectively highlight the facility's failure to maintain the privacy and confidentiality of residents, both in terms of personal exposure and medical information disclosure.
Staffing Deficiencies Lead to Care Issues
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by multiple care issues identified during the survey. Observations and interviews revealed that residents experienced delays in receiving incontinence care, repositioning, and other necessary assistance, particularly during evening and night shifts. Specific instances included residents waiting for extended periods for care, with some reporting that staff were unresponsive or absent. The facility's staffing levels were notably lower on weekends compared to weekdays, contributing to these deficiencies. Residents voiced significant concerns about the lack of staff responsiveness, particularly during night shifts and weekends. Several residents reported waiting for hours for assistance, with some indicating that staff would turn off call lights without providing care. The Resident Council meeting further highlighted these issues, with attendees confirming that call light response times were poor, and incontinence care was often delayed. Additionally, residents reported that food was frequently served cold and not according to their preferences, with trays left sitting in carts for extended periods. The staffing coordinator acknowledged that the facility was understaffed on Sundays and agreed that weekend staffing should match weekday levels. Despite these acknowledgments, the facility consistently operated with fewer CNAs on weekends, exacerbating the care deficiencies. The survey findings underscore the facility's failure to maintain adequate staffing levels, resulting in unmet resident needs and dissatisfaction with care quality.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to respond to a grievance voiced by a resident regarding her roommate's disruptive behavior. Resident #38, who has some cognitive impairment and is on medications for insomnia, depression, and anxiety, expressed her distress about her roommate, Resident #40, who exhibited agitated behavior such as yelling, crying, and throwing objects. Despite Resident #38's repeated complaints about the ongoing disturbances, no action was taken by the staff to address her concerns. The Social Services Assistant (SSA) acknowledged the complaint but did not document it or inform the Social Services Director (SSD), resulting in a lack of follow-up or resolution. The facility's grievance policy requires that grievances be documented and routed to the Grievance Coordinator, but this procedure was not followed in this case. The SSA's failure to report the grievance to the SSD meant that the issue was not addressed, leaving Resident #38's concerns unresolved. The SSD confirmed during an interview that she was unaware of any issues between the two residents, highlighting a breakdown in communication and adherence to the facility's grievance process.
Incomplete PASSAR Documentation for Residents
Penalty
Summary
The facility failed to ensure timely, accurate, and complete PreAdmission Screening and Resident Record Review (PASSARs) for three of four sampled residents. Resident #64 was admitted with diagnoses including Psychosis and Dementia, but no completed Level 1 PASSAR was found in the electronic record until a request was made, and a new PASSAR was completed by the Social Services Director. Resident #78, admitted with Parkinsonism and Psychosis, had an incomplete Level I PASSAR with missing information and no Level II PASSAR, despite indications that one might be required. The Social Services Director acknowledged the inaccuracies in the previous PASSAR completed by the hospital and provided a newly completed Level I PASSAR. Resident #93, admitted with Unspecified Psychosis, Anxiety, Depression, and Dementia, had a Level I PASSAR with several sections left blank, including critical information such as Social Security Number and Medicaid Identification Number. The Social Services Director noted that the PASSARs received from the hospital were often incomplete, sometimes containing only the resident's first name. A fully completed Level I PASSAR was later provided by the Social Services Director. These deficiencies highlight the facility's failure to maintain accurate and complete PASSAR documentation for residents with mental disorders or intellectual disabilities.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to adhere to physician orders regarding blood pressure parameters and medication administration for two residents. Resident #40 was prescribed Midodrine to be held if systolic blood pressure exceeded 130. However, the medication was administered on multiple occasions when the resident's blood pressure was above this threshold, including readings of 131/76, 138/79, and 135/69. Additionally, the medication was inappropriately held when the blood pressure was 108/65. The Unit Manager was informed of these discrepancies but did not provide further information by the time of the Exit Conference. For Resident #73, the facility did not consistently document vital signs as ordered. The resident's care plan required blood pressure and pulse to be recorded twice daily, yet the MAR only showed checkmarks without actual values, and the pulse was documented only 13 out of 127 times. The Unit Manager acknowledged the issue but did not provide additional information before the Exit Conference. Resident #82, who had heart failure and COPD, reported not receiving his prescribed Bumetanide for five days, which he stated affected his breathing and caused swelling. Despite the MAR indicating administration, the resident insisted he did not receive the medication. An LPN confirmed the medication was not available and administered a substitute, Lasix, after consulting the pharmacist and physician. The DON was unable to locate the missing medication in the storage cart, confirming the resident's complaint.
Failure to Provide Prescribed Eyeglasses
Penalty
Summary
The facility failed to provide timely access to prescribed eyeglasses for a resident who had undergone cataract surgery. The resident, who was admitted with diagnoses including congestive heart failure and type 2 diabetes, had been waiting for her prescribed eyeglasses since the surgery in May 2023. Despite having good cognitive function and adequate vision with corrective lenses, the resident reported being unable to read due to not receiving the prescribed eyeglasses. Interviews with the resident and staff revealed that the eyeglasses were reportedly sent to the facility but were lost, and the facility had not effectively tracked or documented the whereabouts of the eyeglasses. The Social Services Director and other staff members were aware of the missing eyeglasses but failed to provide a satisfactory resolution. The facility attempted to provide substitute reading glasses, which were not effective for the resident, and there was a lack of communication with the eye doctor regarding the missing eyeglasses. The facility's policy on visually impaired residents did not include a process for tracking undelivered or missing eyeglasses, contributing to the delay in resolving the issue. Interviews with various staff members, including the Director of Social Services and an LPN, indicated that the resident's complaints about her missing eyeglasses were known but not adequately addressed. The facility's documentation was insufficient, with no progress notes on the resident's complaints until prompted by the surveyor. The lack of a systematic approach to tracking and resolving the issue of the missing eyeglasses resulted in the resident being unable to read for an extended period, highlighting a deficiency in the facility's provision of vision services.
Improper Incontinence Care Leads to Resident Discomfort and Potential UTI
Penalty
Summary
The facility failed to provide proper incontinence care for a resident with a history of urinary tract infections (UTIs). The resident, who was totally dependent on staff for toileting and always incontinent of bowel and bladder, was observed receiving inappropriate care. During an observation, a Certified Nursing Assistant (CNA) was seen cleaning the resident's back side by wiping from the buttock toward the front, contrary to the facility's policy of wiping from front to back. This improper technique was noted despite the resident's visible discomfort and grimacing, which the CNA initially did not acknowledge. The resident's medical records indicated a history of UTIs, with a recent infection caused by E. Coli, suggesting poor incontinence care. Additionally, there were uncompleted orders for urinalysis related to UTI symptoms. The resident's son reported that the resident frequently experienced UTIs at the facility, unlike at home. A skin evaluation revealed a rash on the resident's sacrum, and during the observed care, a diffuse red rash was noted on the resident's upper buttock and lower back. The CNA admitted to not following the correct procedure when questioned, and the Unit Manager was unaware of the resident's condition during the care.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents, as evidenced by several deficiencies in oxygen care and services. Resident #78 was observed with a dirty oxygen concentrator and a nasal cannula misplaced under the resident's eye. The maintenance and housekeeping departments were unclear about their responsibilities regarding the cleaning and maintenance of the oxygen equipment, leading to the equipment remaining in poor condition over several days. Resident #51, who had a tracheostomy, was supposed to have an Ambu bag at the bedside as per physician orders. However, during an interview, the resident was unaware of its location, and neither the surveyor nor the Director of Nursing could initially find it. It was later discovered that the Ambu bag was stored in a different location, indicating a lack of adherence to the physician's order and potential risk in an emergency situation. Resident #31, diagnosed with COPD and other respiratory issues, was observed with oxygen tubing and a nasal cannula wrapped around his wrist, indicating he was not receiving the prescribed oxygen therapy. Despite multiple observations, staff failed to address the issue or ensure the resident was receiving the necessary oxygen therapy. Similarly, Resident #82's oxygen tubing and humidifier were not changed as ordered, and the resident reported that staff did not have the necessary equipment to provide proper care. These failures highlight significant lapses in the facility's respiratory care protocols and staff's adherence to physician orders.
Medication Administration Errors Identified
Penalty
Summary
The medication error rate at the facility was found to be 7.69 percent, exceeding the acceptable threshold of 5 percent. This was identified during a medication administration observation involving two residents. For the first resident, the LPN administered only one 500 mg Methocarbamol tablet instead of the prescribed two tablets. The LPN acknowledged the error upon reviewing the medication order. For the second resident, the LPN administered three medications, including Losartan, which was not due until later in the evening. The error was attributed to the medication appearing on the electronic MAR due to a failure by the morning nurse to either administer or sign off the medication. The Assistant Director of Nursing confirmed this discrepancy upon reviewing the MAR.
Failure to Obtain and Document Laboratory Services
Penalty
Summary
The facility failed to provide timely and appropriate laboratory services for two residents, leading to deficiencies in care. Resident #66, who was cognitively impaired and always incontinent of urine, had three separate physician orders for urinalysis that were not fulfilled. On each occasion, the facility's records lacked documentation of the urinalysis results, and there was no evidence of follow-up actions or communication with the physician to address the inability to collect the urine samples. The Assistant Director of Nursing confirmed the absence of results and documentation during a review, indicating a failure in the facility's process for obtaining and documenting laboratory tests. Similarly, Resident #73 had an order for a comprehensive metabolic panel and complete blood count, which was marked as completed in the Treatment Administration Record. However, the facility's records did not contain any results or further documentation regarding the laboratory services. Despite being informed of the missing blood work, the Second Floor Unit Manager did not provide any additional information by the time of the exit conference, highlighting a lapse in the facility's follow-through on ordered laboratory tests.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that residents were served food at a palatable temperature, affecting several residents who voiced concerns about the temperature of their meals. Resident #82 reported that his meals were sometimes cold, estimating that this occurred about half the time. Resident #89 also mentioned that her meals were sometimes cold. Resident #77, who eats in his room, stated that his food was always cold and noted that the food cart often sat in the hallway before trays were distributed. These residents were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores. Additionally, a review of the grievance log revealed multiple complaints about cold food over the past six months, with resolutions involving reheating meals and staff in-service training. During a special Resident Council meeting, four residents, all cognitively intact, confirmed that food was consistently served cold and that trays often sat in carts for extended periods before being distributed. Despite some recent improvements, the residents noted that these improvements were not consistent.
Failure to Accommodate Dietary Preferences and Needs
Penalty
Summary
The facility failed to provide food according to the preferences and dietary needs of several residents, leading to dissatisfaction and potential health concerns. Resident #104, who is diabetic, reported being served orange juice and foods she dislikes, such as green beans and carrots, without being offered alternatives. Resident #63, who requires double portions due to increased nutritional needs, was served single portions and left the dining room without eating, as no alternative was offered. Resident #107, a vegetarian with specific dietary restrictions, was served a salad containing turkey, contrary to his dietary preferences and physician's orders. The facility's dietary management process was also found lacking. The Dietary Manager stated that food preferences are communicated through a form from nursing and discussed with residents within the first 24 hours of admission. However, Resident #73 reported not receiving a menu to select his choices and expressed frustration when his meal preferences were not honored, such as receiving gravy on his hamburger steak despite his meal ticket specifying no gravy. Resident #77, who prefers double portions, reported that this preference was rarely honored, although it was provided during the survey week. These deficiencies highlight a systemic issue in the facility's ability to accommodate residents' dietary preferences and needs. The dietary staff, including the Dietary Manager, failed to ensure that meal tickets accurately reflected residents' preferences and that alternative options were offered when necessary. This lack of adherence to dietary preferences and orders resulted in dissatisfaction among residents and potential health risks, particularly for those with specific dietary restrictions or increased nutritional needs.
Infection Control and EBP Failures
Penalty
Summary
The facility failed to adhere to proper infection control practices during a blood sugar check for a resident. The Licensed Practical Nurse (LPN) used FitRight Wet Wipes, which are intended for hand hygiene and do not contain disinfecting agents, to clean the glucometer after use. The LPN was unaware of the manufacturer's instructions for the MicroKill Bleach wipes, which require a three-minute wet time to effectively disinfect the glucometer. This oversight in following the correct disinfection procedure was confirmed during an interview with the LPN. Additionally, the facility did not properly implement Enhanced Barrier Precautions (EBP) for a resident with multiple health conditions, including an indwelling urinary catheter and unhealed pressure injuries. The resident was observed to be under EBP, but the Certified Nursing Assistant (CNA) failed to wear a protective gown while performing high-contact care activities, such as perineal care and handling the urinary catheter. The CNA also wore multiple pairs of gloves without changing them between tasks, which compromised the infection control measures. Interviews with other staff members, including another CNA and a Registered Nurse (RN), revealed a lack of awareness regarding the requirement to use gowns as part of the PPE for residents under EBP. The staff emphasized hand washing and glove use but did not mention the necessity of gowns, indicating a gap in the facility's adherence to its own EBP policy. The resident later experienced discomfort and was sent to the hospital due to complications with the urinary catheter.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents across three of its four units. During an initial tour, several deficiencies were observed, including damaged furniture, such as a footboard with jagged edges and a missing nightstand replaced by a plastic bin. Additionally, there were issues with room cleanliness, such as stained privacy curtains, dust accumulation in air-conditioning vents, and brown residue on tube feeding equipment and floors. A strong urine odor was noted in one room, persisting over several days, and a small roach was observed entering a vent. Interviews with the Maintenance Director and Housekeeping Manager revealed communication gaps and unclear responsibilities regarding maintenance and cleanliness. The Maintenance Director, recently hired, indicated that repairs and missing items should be reported by nursing staff through a work order system. The Housekeeping Manager, also new to the position, was unaware of the urine odor issue and stated that CNAs were responsible for cleaning certain equipment during turnover, while housekeeping was responsible during regular cleaning. The environmental tour confirmed these issues, highlighting a lack of awareness and coordination among staff regarding the facility's environmental conditions.
Deficiencies in ADL Care and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for three residents, leading to deficiencies in incontinence care, personal hygiene, and grooming. Resident #45, who has a history of cerebral vascular accident and hemiplegia, reported being left in soiled adult briefs for extended periods, resulting in severe redness in her groin and gluteal area. Despite her cognitive impairment, she was able to communicate her discomfort and the delay in receiving care. Observations confirmed that staff were slow to respond to her needs, with significant delays in changing her soiled briefs. Resident #74, with diagnoses including dorsalgia and muscle weakness, expressed dissatisfaction with the lack of personal grooming, specifically mentioning that his hair had not been shampooed for six months. He also reported infrequent perineal care, often sitting in a wet brief for hours. Despite having good cognitive function, he felt unable to request assistance due to staff being busy. Observations noted his unkempt appearance, with uncombed hair and dirty fingernails, indicating a lack of regular personal hygiene care. Resident #8, who has cognitive impairment and requires assistance with personal hygiene, was observed with dirty fingernails despite having been shaved. His care plan indicated a need for moderate assistance, yet staff failed to routinely clean his nails. The CNA responsible for his care acknowledged the need for cleaning but did not provide a reason for the oversight. This pattern of neglect in personal hygiene and grooming was consistent over several days, as evidenced by staff assignments and observations.
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 177 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 Lake Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine Trail Nursing And Rehab Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Aviata At Coral Bay | 1.1 mi | ★★★★★ | 0 | 0 |
| Beach Breeze Rehab And Care Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Medicana Nursing And Rehab Center | 2.7 mi | ★★★★★ | 1 | 0 |
| Terraces Of Lake Worth Care Center And Rehab | 3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Palm Beach Nursing Center.
100% money-back within 48 hours.
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.