Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Prosper Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to follow its abuse prevention and reporting policies, as staff did not consistently communicate, document, or notify management, physicians, or families about multiple incidents of alleged abuse and resident-to-resident altercations. Several events were not recorded in the EMR, and required notifications were not made, with staff interviews revealing confusion about reporting procedures and incomplete abuse training.
A resident alleged being physically abused by an aide and contacted 911, prompting police and EMS involvement. Although law enforcement found no evidence of abuse, the facility administrator did not report the allegation to the regulatory agency as required, believing it did not meet abuse criteria. The deficiency was identified when a state agency investigated the incident and found the required reporting had not been completed.
A resident's transfer or discharge was not conducted in a manner that met their needs and preferences, and the facility did not ensure the resident was adequately prepared for a safe transition.
The facility failed to ensure proper catheter care and anchoring for two residents, leading to deficiencies in catheter care and increased risk of complications. One resident had improper catheter cleansing and an unsecured catheter, while another had an unadhered catheter anchor, causing the catheter to be pulled during care.
The facility failed to provide mechanical lift slings for several residents, leading to issues with transferring. One resident's family reported that the resident had not been out of bed for 21 days due to the unavailability of a lift sling. Additionally, the facility did not provide a wheelchair for one resident and failed to ensure proper beds or mattresses for two residents.
The facility failed to provide enteral tube feeding as ordered for four residents, leading to inadequate nutritional intake. Observations and staff interviews revealed inconsistencies and deviations from prescribed orders, with no proper documentation to justify the actions.
The facility failed to ensure competent nursing staff for two residents, leading to improper oxygen administration, wound care, and medication administration through a PEG tube. Staff did not follow proper procedures, lacked necessary competencies, and failed to replace an empty water bottle for humidified oxygen.
The facility failed to follow the shower schedule for a resident with bilateral below-the-knee amputation and did not communicate another resident's desire for outdoor activities to the Activity Director. The first resident did not receive scheduled showers due to staff shortages and a missing Hoyer lift pad, while the second resident was unable to go outside because CNAs did not inform the Activity Director of her request.
The facility failed to provide appropriate beneficiary notices for three residents. Two residents received the Notice of Medicare Non-Coverage (NOMNC) on the last day of Part A services instead of two days prior, and neither received the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN). Another resident's expedited appeal was rejected due to insufficient documentation.
The facility failed to provide timely ADL care for three residents, including incontinence care, nail trimming, and mouth care. One resident was found with a soiled brief and long fingernail, another was left in a wheelchair for nearly eight hours, and a third had unmet mouth care needs despite multiple observations by staff.
A resident who was totally dependent on staff and had three pressure injuries did not receive a specialty air mattress and protective boots as documented in their care plan and physician's orders. Observations revealed the resident lying on a regular mattress without protective boots, and staff confirmed the oversight.
The facility failed to ensure documented provision of dialysis and ongoing communication with the dialysis facility for a resident. Missing Dialysis Communication Forms and lack of progress notes on specific dates in March 2024 were identified during a review with the DON.
The facility failed to ensure complete and accurate medical records for several residents, leading to multiple deficiencies. This included missing documentation for treatments, inconsistent height measurements, absence of required pre-admission screening, inaccurate meal consumption records, and contradictory orders related to dialysis and catheter care.
A resident diagnosed with pneumonia experienced a delay in receiving physician-ordered IV antibiotics due to miscommunication and unawareness among staff. Despite the midline being inserted and the medication being available in-house, the antibiotic was not administered until the following morning, resulting in missed doses.
Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement and follow its written policies and procedures to prevent abuse, neglect, and theft, as evidenced by multiple incidents involving several residents. In several cases, staff did not communicate allegations of abuse or resident-to-resident altercations to management, did not document the events in the electronic medical record (EMR), and did not notify physicians or families as required. For example, one resident reported being punched by another resident, but there was no immediate documentation, assessment, or notification to the physician or family, and the incident was not investigated until surveyors brought it to the attention of the Administrator and DON. Staff involved in the incident admitted to not reporting or documenting the event, with some stating they did not believe the incident could have occurred due to the alleged perpetrator's physical limitations or the reporting resident's history of similar allegations. In another incident, a resident found a male resident in her bed and reported it to staff, who removed the resident and relocated him. However, there was no documentation of the incident in the involved residents' records, nor evidence of timely notification to families or physicians. Staff interviews revealed inconsistent understanding of reporting and documentation requirements, with some staff unaware of the need to inform management, families, or physicians, and others believing that reporting was unnecessary if they doubted the allegation. The facility's abuse training was found to be inconsistently applied, with some staff only receiving education after being directly involved in an incident, and others not completing required training modules. Additional incidents included a resident entering another resident's room and exposing himself, with no documentation or notification to management, families, or physicians. Interviews with staff and administration confirmed a lack of awareness of these events until prompted by surveyors, and acknowledged the absence of required documentation. The facility's own policies required immediate reporting, thorough investigation, and documentation of all allegations of abuse, neglect, or mistreatment, but these procedures were not followed in multiple cases, resulting in a failure to protect residents and ensure proper communication and documentation.
Failure to Report Alleged Abuse to Regulatory Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who was admitted for rehabilitation services and assessed as independent with daily decision-making skills and no behaviors. The resident called 911, alleging that an aide had hit him over the head. Police and EMS responded, and the police reviewed a video provided by the resident, determining that no abuse had occurred. The resident was transported to the hospital for evaluation and returned to the facility the same day. The resident subsequently filed a grievance stating that the aide had harassed him multiple times. Documentation showed that the resident did not initially report the alleged abuse to nursing staff but instead contacted emergency services directly. The facility administrator stated that she contacted another state agency regarding the incident but did not complete the required reporting to the regulatory agency, as she did not believe the incident met the criteria for abuse. The administrator also indicated that she was unaware of the abuse allegation until after the fact, upon reviewing hospital records and learning of an open case involving alleged neglect by a family member. An investigator from the state agency confirmed that an investigation was conducted into the allegation of physical abuse, and it was determined that the facility failed to report the allegation to the appropriate regulatory agency as required by policy and federal regulations.
Failure to Ensure Resident-Centered and Safe Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident-centered care and safe transition planning.
Deficient Catheter Care and Anchoring
Penalty
Summary
The facility failed to ensure proper care and services for indwelling urinary catheters for two residents, leading to deficiencies in catheter care and anchoring. For Resident #1, the CNA did not properly secure the catheter tubing in the anchor, resulting in the tubing being pulled taut during care. Additionally, the CNA did not cleanse the catheter tubing correctly, leaving visible brown debris at the insertion site. The LPN was unaware of the cloudy urine and the lack of an attached catheter anchor, which was later confirmed by the Director of Nursing (DON) during an observation and interview. For Resident #67, the catheter anchor was not adhered to the resident's skin, causing the catheter to be pulled during perineal and wound care. Despite the CNA's intention to inform the attending nurse to apply a new anchor, a subsequent observation revealed that the anchor had not been replaced. Resident #67 had a history of UTIs and an indwelling catheter due to a Stage 3 wound, making proper catheter care crucial. The failure to secure the catheter anchor and properly cleanse the catheter tubing contributed to the risk of further complications for both residents.
Failure to Provide Mechanical Lift Slings and Proper Equipment
Penalty
Summary
The facility failed to ensure the provision of mechanical lift slings for 7 of 12 sampled residents who require a mechanical lift for transferring. Additionally, three residents had lift slings without names on them, and 11 of 13 random non-sampled residents either did not have a lift sling, had one with no name on it, or had one belonging to another resident. This deficiency was highlighted by the case of Resident #89, whose family reported that the resident had not been out of bed for 21 days due to the unavailability of a lift sling. The facility also failed to provide a wheelchair for Resident #89 and did not ensure proper bed or mattress for Residents #98 and #260. Resident #89's family brought in their own lift sling, which was subsequently lost, and the resident's daughter reported that staff often had trouble finding lift slings. The surveyor found Resident #19's lift sling in Resident #89's room, and the Nursing Home Administrator confirmed that each resident should have their own lift sling with their name on it. The Central Supply staff indicated that there was only one sling available at the time and had ordered more the previous week. Resident #260 reported that her bed was not inflating properly on one side, and this issue had been ongoing since her admission. Staff interviews revealed that maintenance was not available on weekends to address the bed issue. Resident #98, who is 6 feet 5 inches tall, was observed to be uncomfortable in a standard bed that was too small for him. The Director of Environmental Services confirmed that the resident was on a standard air mattress and needed a larger bed.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to provide nutrition via enteral tube feeding as ordered for four residents. Resident #100, who had severe cognitive impairment and multiple diagnoses including dysphagia, was observed not receiving the prescribed amount of enteral feeding on multiple occasions. Staff interviews revealed inconsistencies in the administration of the feeding, with no documentation justifying the deviations from the prescribed orders. The resident's care plan required strict adherence to physician orders, which was not followed, leading to inadequate nutritional intake. Resident #29, with moderate cognitive impairment and a history of dysphagia, was also not receiving the prescribed amount of enteral feeding. Observations showed discrepancies between the amount of supplement administered and the amount ordered. Staff interviews indicated that the feeding was stopped and restarted multiple times without proper documentation, resulting in the resident not receiving the full prescribed amount of nutrition. Resident #67, who was moderately cognitively impaired and required tube feeding due to malnutrition, was observed receiving the wrong feeding formula. The resident reported spitting up and a bitter taste in her mouth, which was not communicated to the registered dietitian or addressed appropriately. Similarly, Resident #1, who was entirely fed via a tube, had issues with the feeding pump settings and the administration of the correct amount of formula. Staff were observed struggling with the pump and not following the updated orders, leading to the resident not receiving the full prescribed amount of nutrition.
Failure to Ensure Competent Nursing Staff
Penalty
Summary
The facility failed to ensure competent nursing staff during care for two of eight sampled residents. For Resident #1, staff did not have an order for oxygen administration and failed to replace an empty water bottle for the humidified oxygen. Additionally, the staff did not follow proper procedures for wound care and tube feeding, including not changing gloves and gowns appropriately and needing assistance to set up the tube feeding pump. The resident was observed wearing humidified oxygen without a current order, and the water bottle for the oxygen was found empty on multiple occasions. For Resident #23, the staff failed to properly administer medications through the PEG tube. The RN did not follow the facility's policy for administering medications by gravity flow and instead pushed air through the tube, causing medication and water to leak out of the PEG tube. The RN did not notice the leakage and had to repeat the procedure, again pushing air through the tube and causing further leakage. The RN's actions were inconsistent with the facility's policy and demonstrated a lack of competency in administering medications through an enteral tube. These deficiencies were identified through observations, record reviews, interviews, and policy reviews. The staff's actions and inactions, including not following proper procedures and lacking necessary competencies, led to the deficiencies in care for the residents. The facility's failure to ensure competent nursing staff compromised the well-being of the residents involved.
Failure to Follow Shower Schedule and Communicate Resident's Outdoor Activity Requests
Penalty
Summary
The facility failed to follow the shower schedule for Resident #19, who was admitted with diagnoses including anxiety disorder and depression, and had a BIMS score of 15, indicating cognitive intactness. Despite being dependent on staff for activities of daily living due to bilateral below-the-knee amputation, Resident #19 did not receive the scheduled showers twice a week. The resident reported not receiving the required care, including showers, due to staff shortages. The Director of Nursing confirmed the lack of documented evidence for showers in March and April 2024 and acknowledged the issue with the missing Hoyer lift pad, which prevented the resident from getting out of bed for three days during the survey process. Additionally, the facility failed to ensure that a certified nursing assistant communicated Resident #92's desire for outside activities to the Activity Director. Resident #92, who had a BIMS score of 15, expressed a strong desire to go outside but was told by CNAs that they were not permitted or too busy to take her outside. The Activity Director confirmed that if they had been informed, they would have facilitated the resident's request. This lack of communication resulted in the resident being unable to go outside as desired.
Failure to Provide Appropriate Beneficiary Notices
Penalty
Summary
The facility failed to provide appropriate beneficiary notices for three residents reviewed for Beneficiary Protection Notification. For Resident #58, the facility provided the Notice of Medicare Non-Coverage (NOMNC) on the same day that Part A services ended, instead of at least two days prior. Additionally, the resident did not receive the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) despite choosing to remain in the facility. Similarly, Resident #110 received the NOMNC on the last day of Part A services and was not given the SNF ABN. For Resident #89, no documentation of the NOMNC was provided, and an expedited appeal was rejected due to insufficient medical records being submitted within the required timeframe. The Administrator acknowledged the deficiencies and attributed them to a lack of awareness about the requirement for a second beneficiary notice (SNF ABN) when residents are discharged from Part A services with benefit days remaining and choose to stay in the facility. The new Social Services Director, who was recently hired, was not present when the notices for the three residents were provided and therefore could not offer additional information. The failure to provide timely and appropriate beneficiary notices led to non-compliance with regulatory requirements.
Failure to Provide Timely ADL Care
Penalty
Summary
The facility failed to ensure timely Activities of Daily Living (ADL) care for three residents. Resident #23, who was severely cognitively impaired and dependent on staff for all ADL care, was found with a soiled adult brief and draw pad, emitting a strong urine odor. The resident also had an excessively long fingernail that needed trimming. Staff admitted they did not perform walking rounds with the previous shift and were unaware the resident needed to be changed. The Director of Nursing confirmed the resident's need for incontinence care and nail trimming during subsequent observations. Resident #89, who was totally dependent on staff for all ADL care and frequently incontinent, was left in a wheelchair for nearly eight hours without being returned to bed, resulting in the resident being saturated with urine. The resident's family members reported having to beg staff to get her back into bed and noted that the mechanical lift sling was also wet with urine. The resident's daughter expressed frustration with the staff's reluctance to move her mother between the bed and wheelchair. Resident #1, who was totally dependent on staff for all ADL care and received nutrition via a feeding tube, was observed to have a white coating over her teeth and an accumulation of secretions on her bottom lip. Despite multiple observations and interactions with staff, including a CNA and a wound care nurse, the resident's mouth care needs were not adequately addressed. The wound care nurse eventually removed some of the accumulated secretions but acknowledged the need for additional mouth care.
Failure to Provide Specialty Air Mattress and Protective Boots
Penalty
Summary
The facility failed to provide a specialty air mattress and protective boots for a resident who was totally dependent on staff for all Activities of Daily Living and had three current pressure injuries. The resident was admitted to the facility and moved to a new room after a short hospitalization. Despite the care plan documenting the need for a pressure-relieving mattress and protective boots, these interventions were not provided upon the resident's return to the facility. Observations over several days revealed the resident lying on a regular mattress without protective boots, contrary to the physician's wound care progress notes that documented the need for these interventions. The wound care nurse confirmed that the resident had a specialty air mattress in her previous room before hospitalization but had not noticed its absence since the resident's return. The Unit Manager also confirmed the presence of the specialty air mattress in the resident's previous room but did not provide an explanation for its absence in the current room. This oversight led to the resident not receiving the necessary pressure ulcer care as documented in their care plan and physician's orders.
Failure to Document Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure documented provision of dialysis and ongoing communication with the dialysis facility for a resident who required such services. The policy on Dialysis Care, revised in August 2023, mandates that facility personnel provide necessary information to the dialysis center and record correspondence in the plan of care. However, a review of the records for a resident admitted on an unspecified date revealed missing Dialysis Communication Forms for multiple dates in March 2024. Additionally, progress notes lacked evidence of the resident's attendance or refusal of dialysis services on specific dates, and there was no documentation related to the resident's return from dialysis on one occasion. These lapses were identified during a side-by-side review with the Director of Nursing on April 4, 2024.
Inaccurate and Incomplete Medical Records
Penalty
Summary
The facility failed to ensure complete and accurate medical records for several residents, leading to multiple deficiencies. For Resident #20, the March 2024 electronic medication and treatment administration record (eMAR/eTAR) lacked staff initials signifying the completion of various treatments and monitoring tasks for the day shift on 03/29/24. This included treatments for bilateral buttocks, mid-back wound care, sacrum rash, daily body audits, and behavior monitoring. The Director of Nursing (DON) and Administrator were informed of these missing initials and documentation on 04/04/24. Resident #5's electronic health record revealed the absence of a Pre-Admission Screen and Resident Review (PASARR) upon admission. Despite efforts by the Medical Records Clerk, DON, and Administrator to locate the documentation, it was only provided later by the Administrator after reaching out to the previous facility. This delay in documentation could have impacted the resident's care plan and treatment. Resident #98's medical records contained inconsistent height measurements, with the Admission Nursing Evaluation and Nutrition Evaluation documenting the resident as 68 inches tall, while the resident and hospital transfer form indicated a height of 6 feet 5 inches. This discrepancy was acknowledged by the Director of Rehabilitation and the Registered Dietitian, who agreed to reassess the resident's nutritional needs based on the correct height. Additionally, Resident #53's meal consumption documentation was inconsistent and inaccurate, with staff reporting incorrect percentages of food intake, which was crucial for the Registered Dietitian to make necessary dietary adjustments. Lastly, Resident #55's records contained contradictory and inappropriate orders related to dialysis transportation, fistula care, and urinary catheter management, leading to confusion and potential mismanagement of the resident's care. The DON acknowledged that previous orders were not being discontinued upon receipt of new orders, resulting in multiple active and conflicting orders in the electronic Medication Administration Record (MAR).
Delay in Administering IV Antibiotics
Penalty
Summary
The facility failed to ensure the timely provision of physician-ordered antibiotics for a resident who was admitted with a complaint of a cough and later diagnosed with pneumonia. The physician ordered the IV antibiotic Zosyn to be administered every six hours for seven days. However, despite the midline being inserted on the same day, the antibiotic was not administered until the following morning, resulting in missed doses at 6:00 PM and midnight. The resident, who was cognitively intact, confirmed that the IV antibiotics were started the morning after the order was given, indicating a delay in treatment. Interviews with staff revealed confusion and miscommunication regarding the availability and administration of the IV antibiotic. The LPN thought the physician had instructed to continue oral antibiotics until the IV antibiotics were delivered from the pharmacy, despite the medication being available in the in-house stock. The Unit Manager was unaware of the delay, and the physician was under the impression that there was an issue with starting the IV line. This miscommunication and lack of awareness among staff led to the delay in administering the necessary IV antibiotics to the resident.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 140 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Palm Beach Gardens
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gardens Court | 1.1 mi | ★★★★★ | 6 | 0 |
| Nursing Center At La Posada, The | 1.2 mi | ★★★★★ | 0 | 0 |
| Waterford, The | 1.3 mi | ★★★★★ | 0 | 0 |
| North Lake Care Center And Rehab | 3.3 mi | ★★★★★ | 11 | 0 |
| Luxe At Jupiter Rehabilitation Center (the) | 3.9 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.