Above 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 Rehabilitation Center Of The Palm Beaches, The during CMS and state inspections, most recent first.
Surveyors found multiple unsealed conduit penetrations and improper fire stopping materials in the fire and smoke barriers of an electrical room. The facility could not provide documentation that the materials used were approved for fire stopping, and several areas had visible breaches in the rated walls, indicating noncompliance with NFPA 101 standards.
Surveyors found that after the removal of a drop ceiling in an electrical room, two sprinkler heads were left too far below the new ceiling, resulting in inadequate sprinkler coverage and noncompliance with NFPA 101 and NFPA 13 requirements. The Maintenance Director confirmed the findings during the facility tour.
A facility failed to honor a resident's shower schedule, as requested by the resident's representative. The resident, with severe cognitive impairment and dependent on care, was scheduled for showers twice a week. However, records showed the resident received bed and tub baths instead. A note from the resident's sister requested adherence to the shower schedule, but staff interviews confirmed the lack of showers and absence of a tub in the facility.
A facility failed to accurately document the discharge status of a resident who was discharged home, as the MDS assessment incorrectly recorded the discharge as to a 'Short-Term General Hospital'. The resident, with multiple diagnoses, was discharged with all necessary instructions and medications, but the error was confirmed by the MDS Coordinator, who planned to update the assessment.
The facility failed to follow physician orders for several residents, including not applying prescribed antifungal cream, not administering blood pressure medication as needed, and not arranging a urology consultation. These deficiencies were due to lapses in medication management, inconsistent monitoring, and lack of follow-up care.
A resident with severe cognitive impairment was not provided adequate hydration due to staff mishandling her fluid restriction orders. Despite being on a 1200 ml/day fluid restriction, her juices were frequently discarded by aides, leaving her with dry lips and feeling depressed. The resident's complaints were confirmed during an observation where she discussed the issue with the MDS coordinator, who promised to inform the aides not to remove her juice.
A facility failed to ensure timely physician visits for a resident with a catheter. The resident, who had mild cognitive impairment and was dependent on staff for ADLs, experienced a significant gap in physician evaluations, with no visits recorded between late August and early November. This deficiency was acknowledged by the DON during an interview.
A resident with mild cognitive impairment and dependence on staff for ADLs did not receive timely physician visits following readmission from the hospital, as required by regulation. Review of records showed a gap in physician evaluations, which was acknowledged by the DON.
The facility did not meet the required daily average of 2.0 CNA hours per resident on multiple days during the first quarter of FY 2025, with daily averages falling below the standard. The DON acknowledged these findings during the survey. This constitutes a Class III deficiency.
The facility did not properly post daily nursing staff information, as required, by listing only names without titles or unit assignments. This made it unclear which nurses or CNAs were responsible for specific residents, and both surveyors and residents could not determine staff assignments from the posted information. The ADON acknowledged these deficiencies.
A resident who was fully dependent for care did not receive scheduled showers as requested by her representative, despite a posted note and care plan specifying shower days. Instead, the resident received bed baths and tub baths, with staff and DON confirming the lack of shower documentation and the absence of a tub in the facility.
Surveyors found that the facility failed to ensure a resident on fluid restriction received her allowed fluids, did not provide a prescribed skin cream to another resident due to lack of supply, and did not consistently monitor or document blood pressure for a resident with hypertension as ordered. Additionally, a required follow-up consultation for another resident was not completed or documented.
A resident with multiple diagnoses was discharged home as documented in care plans, progress notes, and social services records. However, the MDS discharge assessment incorrectly recorded the discharge status as 'Short-Term General Hospital' instead of home. The MDS Coordinator confirmed the error and indicated the assessment would be updated.
Failure to Maintain Fire/Smoke Barrier Integrity in Electrical Room
Penalty
Summary
During an unannounced Fire & Life Safety revisit survey, surveyors observed that the facility failed to maintain proper fire and smoke barrier construction in accordance with NFPA 101 standards. Specifically, in Electrical Room #6, there were five open conduit penetrations through the south side 1-hour fire rated wall and three penetrations through the north side smoke wall. Additionally, thirteen areas on the east and south side 1-hour fire rated walls were found with red fire stopping mixed with a white putty, as well as areas with only white putty surrounding the penetrating conduit. The facility was unable to provide documentation confirming that the white putty used was approved for fire stopping purposes. These deficiencies were identified during a fire safety tour conducted with the Administrator and the Maintenance Director, who acknowledged the findings at the time of observation. The surveyors noted that these examples may not represent all unprotected penetrations in the facility's fire and smoke barriers, emphasizing the need for a thorough inspection of each barrier along its full length and height to ensure all penetrations are properly sealed. The report further states that every breach or penetration of a fire barrier must be appropriately repaired to restore the wall, ceiling, or floor to its original fire or smoke rated integrity. The penetrations in fire rated barriers are required to be sealed with a UL (Underwriters Laboratories) listed approved system. Photographic evidence was obtained to document the observed deficiencies.
Plan Of Correction
6/6/25 Preparation and/or execution of this plan of correction does not constitute admission or agreement of the provider of the truth of the alleged or conclusion set forth in the CMS measured star ratings. The plan of correction is prepared and executed solely because it is required by Federal and State Laws. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. No residents were affected by this alleged deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: 2. The facility will maintain the fire/smoke barrier construction in Electrical room #5. Penetration holes five (5) through the South side; three through the North side smoke wall; thirteen (13) areas on the East and South side 1-hour fire rated walls were resealed by a 3M trained professional in accordance with NFPA 101. A thorough inspection of each fire/smoke barrier will be conducted to ensure that all penetrations are found and properly sealed in accordance with NFPA 101. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: 3. Maintenance staff re-educated on ensuring fire/smoke barrier penetrations are inspected along its full length, height and properly sealed with a UL (Underwriters Laboratories) listed approved system. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: 4. Maintenance Director or Designee will report the findings of fire/smoke barrier penetrations audits to the QAA&C monthly times three months or until substantial compliance is met. Preparation and/or execution of this plan of correction does not constitute admission or agreement of the provider of the truth of the alleged or conclusion set forth in the CMS measured star ratings. The plan of correction is prepared and executed solely because it is required by Federal and State Laws. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. No residents were affected by this alleged deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: 2. The facility will maintain the fire/smoke barrier construction in Electrical room #5. Penetration holes five (5) through the South side; three through the North side smoke wall; thirteen (13) areas on the East and South side 1-hour fire rated walls were resealed by a 3M trained professional in accordance with NFPA 101. A thorough inspection of each fire/smoke barrier will be conducted to ensure that all penetrations are found and properly sealed in accordance with NFPA 101. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: 3. Maintenance staff re-educated on ensuring fire/smoke barrier penetrations are inspected along its full length, height and properly sealed with a UL (Underwriters Laboratories) listed approved system. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: 4. Maintenance Director or Designee will report the findings of fire/smoke barrier penetrations audits to the QAA&C monthly times three months or until substantial compliance is met.
Sprinkler System Installation Noncompliance Due to Ceiling Modification
Penalty
Summary
During an unannounced Fire & Life Safety recertification survey, it was observed that the facility failed to maintain their sprinkler system installation in accordance with NFPA 101 and NFPA 13 standards. Specifically, in Electrical Room #5, the drop ceiling had been removed, resulting in two sprinkler heads being positioned too far below the new ceiling level. This alteration led to inadequate coverage by the sprinkler system in that room, as the sprinkler heads were no longer properly aligned with the ceiling as required by code. The deficiency was identified during a facility tour conducted with the Maintenance Director, who confirmed the findings during an interview. The issue was reviewed with both the Administrator and the Maintenance Director at the exit conference, and photographic evidence was obtained to document the noncompliance. No information regarding residents or their medical conditions was included in the report, and the deficiency was limited to the physical plant and fire safety systems.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement of the provider of the truth of the alleged or conclusion set forth in the CMS measured star ratings. The plan of correction is prepared and executed solely because it is required by Federal and State Laws. K351 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. No residents were affected by this alleged deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: 2. The facility will maintain the supervised automatic fire sprinkler system in accordance with NFPA 101. Electrical Room #5 is scheduled to be corrected on 4/15/25 to ensure adequate coverage of the automatic fire sprinkler system protection in accordance with NFPA 101. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: 3. Maintenance staff re-educated on ensuring inspection of every compartment for sprinkler system. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: 4. Maintenance Director or Designee will report the findings of the automatic fire sprinkler audits to the QAA&C monthly times three months or until substantial compliance is met.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to honor the resident representative's request to ensure that a resident received a shower on the scheduled shower days. The resident, who was admitted to the facility with severe cognitive impairment and was dependent on all care needs, had a shower schedule set for every Monday and Thursday during the 3 PM - 11 PM shift. However, documentation from the CNA task list showed that the resident received only four bed baths and three tub baths on the scheduled shower days between February 27 and March 24. An observation in the resident's room revealed a note written by the resident's sister, requesting that the resident receive a shower on her shower days. Interviews with staff confirmed the lack of shower documentation and revealed that the facility did not have a tub, which contributed to the deficiency.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement of the provider of the truth of the alleged or conclusion set forth in the CMS measured star ratings. The plan of correction is prepared and executed solely because it is required by Federal and State Laws. F561 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #71 was provided with a shower as scheduled. Staff C was re-educated to provide and document showers provided on residents' shower days and any additional days that the residents receive a shower. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: Facility audit conducted to ensure residents' showers are completed on scheduled shower days and documented appropriately. Other residents found to be affected were corrected. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Certified Nursing Assistants (C.N.As) have been re-educated regarding Resident Rights/Right of Choices as related to receiving shower on the scheduled shower days. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: Random observation will be conducted three times per week / three months to ensure compliance. Director of Nursing/Designee will conduct weekly shower audits times four weeks and will report the findings of the audits to the QAA&C monthly times three months or until substantial compliance is met.
Inaccurate Discharge Documentation for a Resident
Penalty
Summary
The facility failed to accurately document the discharge status of a resident, identified as Resident #100, who was reviewed as part of closed records. Resident #100 was admitted with multiple diagnoses including anemia, hypertension, hip fracture, and chronic pain syndrome. The care plan for discharge indicated the resident's or responsible party's wish to return home, with a goal to safely discharge to a lower level of care once rehabilitation goals were met. On the day of discharge, progress notes documented that the resident was discharged home via private car, accompanied by two persons, with all necessary instructions and medications provided. However, the Minimum Data Set (MDS) assessment inaccurately recorded the resident's discharge status as 'Short-Term General Hospital' instead of home. This discrepancy was confirmed during an interview with the MDS Coordinator, who acknowledged the error and stated that the assessment would be updated and resubmitted. The failure to accurately document the discharge status represents a deficiency in ensuring each resident receives an accurate assessment.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #100 assessment was corrected by the Clinical Reimbursement Director and resubmitted. No other residents were affected by the deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: The Clinical Reimbursement Director/designee reviewed discharged residents for the last 30 days to ensure accurate documentation for discharge. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: The Clinical Reimbursement Director/designee will educate the Clinical Reimbursement staff on proper documentation and capturing discharge information accurately, including assessment of discharge destination. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: The Clinical Reimbursement Director/designee will audit discharge care plans and assessments for appropriate discharge status. Audits will be conducted weekly for four weeks, with findings reported monthly for three months at QAA&C or until substantial compliance is met.
Failure to Follow Physician Orders and Medication Management
Penalty
Summary
The facility failed to adhere to physician orders for multiple residents, leading to deficiencies in care. For one resident with severe cognitive impairment, the facility did not apply the prescribed antifungal cream as ordered. Observations revealed the resident was experiencing significant discomfort due to a rash, and interviews with staff indicated that the antifungal cream was not available due to a failure to reorder it after the stock expired. Despite the treatment administration record indicating that the cream had been administered, it was confirmed that the medication was not available, highlighting a lapse in medication management and communication among staff. Another resident, who was cognitively intact and diagnosed with hypertension, did not receive the necessary blood pressure monitoring and medication as needed. The resident's care plan required the administration of Catapres for high systolic blood pressure, but the facility did not document blood pressure readings consistently, nor did they administer the medication when required. Interviews with nursing staff revealed inconsistencies in the process of monitoring and documenting blood pressure, which contributed to the oversight in providing the necessary medication. Additionally, the facility failed to follow through with a physician's order for a urology consultation for a resident with an indwelling catheter and a diagnosis of hemorrhagic cystitis. The resident's records showed no documentation of a follow-up with urology, nor any indication that the resident refused the consultation. The Director of Nursing acknowledged the oversight, indicating a failure in ensuring that critical follow-up care was arranged and documented for the resident.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. The was obtained from the vendor and provided the unit on in the afternoon. Resident #5 was provided with the cream as ordered. The Physician for Resident #5 was notified and will continue with treatment plan. Resident #5 had physician and family notified of medication omissions and new orders received for medication administration with no negative outcomes to the patient. Nurse D, Staff F, and Unit Manager were re-educated on the process of following physician orders and timely ordering of supplies. Central Supply Clerk re-educated on timely ordering of supplies. 2. Resident #58 medication was given as ordered. Medication review completed by physician and the continued to be as needed Q 8 hours. Order provided to monitor 3 times/day and as needed. Licensed nurses re-educated on documenting the for Resident #58 every eight hours as ordered and PRN. 3. Resident #63's consultation was rescheduled from to per family request. The physician was notified of the change of the consultation date. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: A facility-wide audit was completed for current residents to identify any other residents affected by the deficient practice. No other residents were affected by the deficient practice. Current residents' Treatment Administration Records have been audited by the Director of Nursing/designee to ensure compliance with following physicians' orders. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Licensed nurses will be re-educated on the importance of following physician orders related to Quality of Care including customer service, monitoring, and follow-up care for those residents with rashes, medication monitoring, ensuring consultations are scheduled timely. Compliance will be monitored through audits three times a week, four weeks, and weekly thereafter to ensure the practice does not recur. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: The Director of Nursing/designee will conduct treatment observations and consultation audits weekly for four weeks and then monthly for two months to ensure continued compliance. The Director of Nursing/Designee will report the findings of the audits to the QAA&C monthly times three months or until substantial compliance is met.
Inadequate Hydration Due to Mishandling of Fluid Restriction
Penalty
Summary
The facility failed to provide adequate hydration for a resident with severe cognitive impairment, as evidenced by the mishandling of her fluid restriction orders. The resident was on a 1200 milliliters per day fluid restriction, with 900 milliliters to be provided by dietary and 300 milliliters by nursing. Despite these orders, the resident reported that her fluids were frequently taken away by aides, leaving her with dry lips and a feeling of depression. During an interview, the resident expressed that her juices, which she liked to sip on throughout the day, were often discarded by staff, despite requests for them not to do so. An observation confirmed the resident's complaint, as she was seen discussing the issue with the MDS coordinator, who promised to inform the aides not to remove her juice.
Plan Of Correction
F 692 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #16 was provided with additional fluid; no other residents were affected by the deficient practice. Resident's BIM score was redone and now 11. Psych services provided for emotional support and Licensed nurses and Certified Nursing Assistants were educated on sufficient fluid intake to maintain proper hydration and health. Additionally, not removing the fluids allowed to the residents. Care plan updated to reflect resident's preference to sip on her drink throughout the day. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: Facility audit completed for residents on fluid restrictions to ensure they are receiving adequate hydration as ordered. Director of Nursing/Designee to audit/monitor documentation weekly times four weeks. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Assistant Director of Nursing/designee will re-educate nursing staff on the following: Ensure residents with fluid restrictions have adequate time for consumption. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: Will conduct audits weekly times four weeks. Director of Nursing /designee will report findings at monthly QAA&C monthly times three months or until substantial compliance is achieved.
Failure to Ensure Timely Physician Visits for Resident with Catheter
Penalty
Summary
The facility failed to ensure timely physician visits for a resident with a catheter. The resident, who had mild cognitive impairment and was dependent on staff for activities of daily living, was admitted to the facility and later hospitalized before being readmitted. A review of the resident's physician progress notes revealed a significant gap in physician evaluations, with no evidence of a physician visit between late August and early November. This deficiency was acknowledged by the Director of Nursing during an interview.
Plan Of Correction
F712/N55 - Physician Visits - Ensure Physicians visits in a timely manner What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. Resident #63 was seen on. The Physician assigned was re-educated on timely documentation and submission to the facility as required. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: 2. Current residents' charts have been audited over the past 30 days and timely Physician visits are in place. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: 3. Medical Records have been in-serviced on monitoring timely Physician visits. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: 4. Medical Records/designee will audit Physician's progress notes biweekly for timely visits times four weeks and report findings to QAA&C committee for three months or until substantial compliance is met.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that a resident received timely physician visits as required by 59A-4.107(6), FAC. Specifically, after being readmitted to the facility following a hospitalization, the resident's records showed a lack of physician progress notes for a period extending from the date of readmission through a subsequent period, with only one progress note documented. This gap in physician evaluation was confirmed during an interview with the DON, who acknowledged the absence of timely physician visits for the resident. The resident in question had mild cognitive impairment and was dependent on staff for activities of daily living (ADLs).
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. Resident #63 was seen on. The Physician assigned was re-educated on timely documentation and submission to the facility as required. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: 2. Current residents' charts have been audited over the past 30 days, and timely Physician visits are in place. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: 3. Medical Records have been in-serviced on monitoring timely Physician visits. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: 4. Medical Records/designee will audit Physician's progress notes biweekly for timely visits times four weeks and report findings to QAA&C committee for three months or until substantial compliance is met.
Failure to Meet Minimum CNA Staffing Requirements
Penalty
Summary
The facility failed to meet the daily average minimum staffing requirement for Certified Nurse Assistants (CNAs) during the first quarter of Fiscal Year 2025. A review of the State Minimum Nursing Staff for Long Term Care Facilities showed that on several days, the facility's daily average CNA hours fell below the required 2.0 hours per resident per day. Specifically, the daily average CNA hours recorded were 1.9411, 1.9316, 1.9837, and 1.8799 on different days within the quarter. This deficiency was confirmed during an interview with the Director of Nursing (DON), who acknowledged the findings. The report does not mention any specific residents affected or provide details about their medical history or condition at the time of the deficiency. The deficiency is classified as a Class III violation.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement of the provider of the truth of the alleged or conclusion set forth in the CMS measured star ratings. The plan of correction is prepared and executed solely because it is required by Federal and State Laws. N63- What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The staffing coordinator and Nurse Managers have been re-educated on ensuring that Certified Nursing Assistant minimum daily hour of direct care is at least 2.0 per resident per day. No residents were affected by the deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: Audit completed for the past 30 days, and no deficient practice identified. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Nursing Home Administrator educated the Director of Nursing and those responsible for staffing on the requirements of meeting the daily per patient day direct care hours.
Failure to Properly Post Nursing Staff Information
Penalty
Summary
The facility failed to comply with statutory requirements for daily posting of nursing staff information. During observations, the posted staff list across from the nursing station included only names, without specifying titles such as licensed nurses or certified nursing assistants (CNAs). Additionally, the posting did not indicate room assignments for the four units, making it unclear which staff members were responsible for specific residents. Surveyors had to ask staff to determine which personnel were assigned to particular residents, and random residents questioned were unable to identify their assigned nurse by looking at the posted information. The Assistant Director of Nursing confirmed these findings during an interview.
Plan Of Correction
The Nursing Home Administrator, Director of Nursing, and Staffing Coordinator during staffing meetings will continue to ensure compliance with the requirement. On weekends, the Director of Nursing will verify with the Supervisor and monitor callouts for replacements. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee will review findings weekly times four weeks and report compliance during the monthly QA&A Committee monthly times three months or until substantial compliance is met. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The missing staffing information such as titles and room assignments for the Certified Nursing Assistants and Licensed Nurses identified were corrected. No residents were affected by the deficient practice. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: Meeting scheduled with the resident council on to review the posted assignments to ensure understanding. Random residents will be questioned on who their assigned nurses and the Certified Nursing Assistants are to ensure understanding. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Nurse Managers and Licensed Nurses have been re-educated regarding posting nurse staffing information to include titles and room assignments. Weekly audits will be completed to ensure compliance times four weeks. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee will review findings weekly times four weeks and report compliance during the monthly QA&A Committee monthly times three months or until substantial compliance is met.
Failure to Provide Scheduled Showers per Resident Representative's Request
Penalty
Summary
The facility failed to honor a resident representative's request to ensure that a resident received showers on their scheduled shower days. The resident, who was dependent for all care needs as indicated by a Minimum Data Set (MDS) assessment score of 3, had a posted note from her sister on the bulletin board requesting that she receive showers on her scheduled days. The resident's care plan included showers every Monday and Thursday during the 3 PM-11 PM shift. Record review showed that, instead of showers, the resident received four bed baths and three tub baths on the scheduled shower days. Staff interviews confirmed that a bed bath was provided instead of a shower, and the Director of Nursing verified the lack of shower documentation on the CNA task list. It was also confirmed that the facility does not have a tub, further indicating that the resident did not receive showers as scheduled.
Plan Of Correction
N 181 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #71 was provided with a shower as scheduled. Staff C was re-educated to provide and document showers provided on residents' shower days and any additional days that the residents receive a shower. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: Facility audit conducted to ensure residents' showers are completed on scheduled shower days and documented appropriately. Other residents found to be affected were corrected. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: Certified Nursing Assistants (C.N.As) have been re-educated regarding Resident Rights/Right of Choices as related to receiving shower on the scheduled shower days. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in place: Random observation will be conducted three times per week/three months to ensure compliance. Director of Nursing/Designee will conduct weekly shower audits times four weeks and will report the findings of the audits to the QAA&C monthly times three months or until substantial compliance is met.
Failure to Provide Adequate Hydration, Medication Administration, and Physician-Ordered Consultations
Penalty
Summary
The facility failed to provide adequate and appropriate health care to several residents as evidenced by multiple deficiencies. One resident on a 1200 mL per day fluid restriction, with specific allocations for dietary and nursing staff, was not able to access the fluids she was allowed. The resident reported that staff repeatedly removed her juice before she could finish it, despite her requests to leave it for her to sip throughout the day. Observations confirmed the resident's complaints, and staff acknowledged the issue but only offered to replace the juice after it was taken away. Another resident with a severe cognitive impairment had a physician's order for a specific cream to be applied to affected skin areas during the day and evening shifts. Despite this order, the cream was not available for use, as the supply had run out and expired stock had been discarded without timely reordering. Staff interviews revealed that the cream had been unavailable for several days, and the Treatment Administration Record showed that nurses had signed off on the administration of the cream even though it was not actually provided. The resident was observed scratching her arms and had visible skin issues, indicating the treatment was not being administered as ordered. A third resident with a history of hypertension had physician orders for routine and as-needed antihypertensive medications, with instructions to administer the as-needed medication for blood pressure readings above a certain threshold. However, staff were not consistently monitoring or documenting the resident's blood pressure every eight hours as required, resulting in missed opportunities to administer the as-needed medication when indicated. Interviews with nursing staff revealed inconsistent practices in monitoring and documentation, and review of records confirmed that blood pressure readings were not taken or recorded as frequently as ordered. Additionally, another resident did not receive a required follow-up consultation as ordered by the physician, with no documentation of refusal or completion.
Plan Of Correction
1. Resident #16 was provided with additional fluid; no other residents were affected by the deficient practice. Resident's BIM score was redone and now 11. Psych services provided for emotional support and Licensed nurses and Certified Nursing Assistants were educated on sufficient fluid intake to maintain proper hydration and health. Additionally, not removing the fluids allowed to the residents. Care plan updated to reflect resident's preference to sip on her drink throughout the day. Facility audit completed for residents on fluid restrictions to ensure they are receiving adequate hydration as ordered. Director of Nursing/Designee to audit/monitor documentation weekly times four weeks. Assistant Director of Nursing/designee will re-educate nursing staff on the following: Ensure residents with fluid restrictions have adequate time for consumption. Will conduct audits weekly times four weeks. Director of Nursing/designee will report findings at monthly QAA&C meetings monthly times three months or until substantial compliance is achieved. 2. The was obtained from the vendor and provided the unit on in the afternoon. Resident #5 was provided with the cream as ordered. The Physician for Resident #5 was notified and will continue with treatment plan. Resident #5 had physician and family notified of medication omissions and new orders received for medication administration with no negative outcomes to the patient. Nurse D, Staff F, and Unit Manager were re-educated on the process of following physician orders and timely ordering of supplies. Central Supply Clerk re-educated on timely ordering of supplies. 3. Resident #58 medication was given as ordered. Medication review completed by physician and the continued to be as needed Q 8 hours. Order provided to monitor three times/day and as needed. Licensed nurses were re-educated on documenting the for Resident #58 every eight hours as ordered and PRN. 4. Resident #63's consultation was rescheduled from to per family request. The physician was notified of the change of the consultation date. A facility-wide audit was completed for current residents to identify any other residents affected by the deficient practice. No other residents were affected by the deficient practice. Current residents' Treatment Administration Records have been audited by the Director of Nursing/designee to ensure compliance with following physicians' orders. Licensed nurses will be re-educated on the importance of following physician orders related to Quality of Care including customer service, monitoring, and follow-up care for those residents with rashes, medication monitoring, and ensuring consultations are scheduled timely. Compliance will be monitored through audits three times a week, four weeks, and weekly thereafter to ensure the practice does not recur. The Director of Nursing/designee will conduct treatment observations and consultation audits weekly for four weeks and then monthly for two months to ensure continued compliance. The Director of Nursing/Designee will report the findings of the audits to the QAA&C monthly times three months or until substantial compliance is met.
Inaccurate Documentation of Resident Discharge Status
Penalty
Summary
The facility failed to accurately document the discharge status of a resident, as required by 59A-4.109(1), FAC, which mandates a comprehensive and accurate assessment of each resident's functional capacity and discharge status. The resident in question was admitted with diagnoses including wasting and atrophy, abnormalities of gait and mobility, and was documented in the care plan as wishing to return home. The care plan goal was to safely discharge the resident to a lower level of care, such as home, when rehabilitation goals were met. Progress notes and social services documentation confirmed that the resident was discharged home, with details indicating the resident left the facility via private car, accompanied by two persons, and received food and medication as ordered prior to departure. The resident was alert, oriented, and independent in decision-making, and had requested to be discharged home to coincide with the discharge of a spouse from the hospital. Durable medical equipment was ordered for the resident prior to discharge. Despite this, the Minimum Data Set (MDS) discharge assessment inaccurately recorded the resident's discharge status as 'Short-Term General Hospital' instead of home. During an interview, the MDS Coordinator confirmed the resident was discharged home and acknowledged the error in the MDS assessment, stating that it would be updated and resubmitted.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Palm Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edward J Healey Rehabilitation And Nursing Center | 2 mi | ★★★★★ | 0 | 0 |
| Colonial Skilled Nursing Facility Llc | 2 mi | ★★★★★ | 0 | 0 |
| Joseph L Morse Health Center Inc The | 2.1 mi | ★★★★★ | 1 | 0 |
| Lakeside Health Center | 2.1 mi | ★★★★★ | 2 | 0 |
| Westgate Health And Rehabilitation Center | 2.1 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.