Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Terraces Of Lake Worth Care Center And Rehab during CMS and state inspections, most recent first.
Two residents receiving in-house dialysis, both at risk for skin impairment, repeatedly complained about the discomfort and hardness of the dialysis chairs during treatment. Despite voicing their concerns to staff and the dialysis center, the facility did not formally document or address these grievances according to its policy, and the grievance log showed no related entries. Staff interviews confirmed that the complaints were not properly investigated or resolved.
A resident with quadriplegia and paraplegia was documented in the MDS assessment as having no upper or lower extremity impairment, despite medical records, care plans, and interviews with the resident and spouse confirming significant loss of movement and sensation. The resident required substantial assistance with hygiene and bathing, highlighting a discrepancy between actual condition and MDS documentation.
Surveyors found that two residents were given medications not matching physician orders, including the administration of a probiotic not prescribed and the failure to provide prescribed Albuterol inhalation treatments. Additionally, a resident with hypertension received Hydralazine despite blood pressure readings below the physician-ordered parameters, with staff confirming no policy for such situations.
The facility did not provide required safety devices, such as smoking aprons, or maintain proper supervision for several residents during smoking times, despite care plans and assessments indicating these needs. Staff failed to consistently identify residents who required interventions, did not conduct timely smoking safety assessments, and allowed residents to keep smoking materials on their person, contrary to policy. These actions and inactions resulted in noncompliance with the facility's own smoking safety procedures.
A resident with quadriplegia, paraplegia, and an indwelling Foley catheter experienced multiple UTIs, including ESBL infections, and was treated with antibiotics. Despite documentation from medical staff indicating the need for a urology consult, there was no evidence that a consult was requested or completed, and the resident was not informed of any appointment. Staff were unable to confirm or provide documentation of a urology consult.
A resident with a physician-ordered fluid restriction due to multiple medical conditions was observed to have unrestricted access to fluids, with large cups of water regularly available at the bedside. Staff interviews revealed a lack of awareness of the fluid restriction order, leading to the resident receiving more fluids than prescribed, contrary to the care plan and medical orders.
The facility did not consistently monitor or document behaviors and side effects for residents prescribed psychotropic medications, as required by policy and physician orders. For three residents with varying cognitive and psychiatric conditions, there were multiple shifts and days with missing documentation of required monitoring, despite staff acknowledging the expectation to complete these tasks every shift.
Surveyors identified that the medication error rate exceeded 5% due to six errors observed during medication administration for two residents. Errors included an LPN administering a probiotic not ordered by the physician and documenting medications as given on time when they were actually administered late, without proper documentation or explanation. Facility policy on medication administration and documentation was not followed, as confirmed by the ADON.
A resident with hypertension, who was cognitively intact, reported not seeing the attending physician and only being seen by the APRN. Review of the medical record confirmed the absence of physician visit notes, and the physician later admitted he had not uploaded visit documentation for about a year, instead keeping records in his own EMR. This resulted in a failure to maintain required physician visit documentation in the resident's medical record.
Staff failed to follow infection control protocols, including proper use of PPE for a resident on Enhanced Barrier Precautions, disinfection of vital signs equipment by an LPN during medication pass, and maintaining urinary catheter drainage bags off the floor for two residents. Staff demonstrated inconsistent knowledge and application of facility and CDC infection control guidelines.
Failure to Address and Document Grievances Regarding Dialysis Chair Discomfort
Penalty
Summary
The facility failed to initiate and act on grievances regarding the discomfort of dialysis chairs, as reported by two residents receiving in-house dialysis. Both residents, who were cognitively intact and had significant risk factors for skin impairment, voiced repeated concerns about the hardness and discomfort of the dialysis chairs during their treatment sessions. One resident, with a history of pressure ulcers and ongoing wound care, specifically reported that the chair exacerbated her pain and discomfort, and that she had communicated her concerns to both the dialysis center and facility staff. The other resident also reported significant discomfort and pain from sitting in the dialysis chair for extended periods during her treatments. Despite these complaints, there was no evidence that the facility formally documented or addressed these grievances in accordance with its own grievance policy. The policy required prompt efforts to resolve grievances, written responses, and investigation by a designated grievance officer. Interviews with facility staff, including the wound care nurse, Rehab Director, ADON, and social worker, revealed a lack of clarity and follow-through regarding the residents' complaints. Staff acknowledged that a grievance should have been initiated but could not provide documentation or a clear account of how the concerns were addressed. Additionally, review of the facility's grievance log showed no entries related to the dialysis chair complaints from either resident. The issue was only discussed informally during an interdisciplinary team meeting after repeated resident complaints, and no formal trial or intervention was documented prior to surveyor inquiry. The lack of documented action and failure to follow the established grievance process resulted in the residents' concerns not being properly addressed or resolved.
Inaccurate Documentation of Extremity Impairment in MDS Assessment
Penalty
Summary
The facility failed to accurately document the upper and lower extremity impairment status for one resident with significant neurological diagnoses, including quadriplegia and paraplegia. Review of the Minimum Data Set (MDS) assessment indicated that the resident was documented as having no impairment in both upper and lower extremities, despite medical records and care plans noting a history of quadriplegia and paraplegia, which are conditions characterized by loss of movement and sensation. The MDS also recorded the resident as dependent or requiring substantial assistance for toileting hygiene and bathing, which further contradicts the documentation of no impairment in extremities. Interviews with the resident and the resident's spouse confirmed that the resident had no sensation from the chest down, with only minimal functional ability in one hand, and limited grasping abilities in both hands. The resident reported difficulty moving fingers and performing tasks, and the spouse corroborated these limitations. When questioned, the Regional MDS consultant stated that any capacity to move a joint was considered as no impairment, but did not provide a clear response regarding the documentation of impairment for residents with paraplegia or hemiplegia. This discrepancy between the resident's actual condition and the MDS documentation led to the identified deficiency.
Medication Administration and Physician Order Adherence Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to medication administration and adherence to physician orders. In one instance, a resident with diagnoses including protein-calorie malnutrition and dementia was administered Lactobacillus 250mg orally during a medication pass, despite the physician's order specifying Florastor Oral Capsule 250mg (Saccharomyces boulardii) for a limited duration, which had already been discontinued. Both the LPN and the Assistant Director of Nursing initially stated that the two medications were the same, but later clarified that they were only similar, not identical. Another deficiency involved a resident with chronic obstructive pulmonary disease (COPD) and other comorbidities who did not receive prescribed Albuterol inhalation treatments after a certain date. The resident reported that the treatments, which had previously helped her breathe easier, were suddenly stopped without explanation, and staff were unaware of the current orders for Albuterol. The medication administration record confirmed that the treatment was not given as ordered, and staff interviews revealed a lack of knowledge regarding the resident's medication regimen. A further issue was found with a resident diagnosed with hypertension who received Hydralazine 50mg despite physician orders to hold the medication if the systolic blood pressure was below 110 or the heart rate was below 60. Medication administration records showed that the medication was given on two occasions when the resident's systolic blood pressure was below the specified threshold. The regional nurse consultant confirmed that there was no policy in place regarding the administration of blood pressure medications with such parameters, and the medication was administered contrary to the physician's instructions.
Failure to Provide Safe Smoking Environment and Supervision
Penalty
Summary
The facility failed to ensure a safe smoking environment for multiple residents by not providing required safety devices, such as smoking aprons, and not maintaining supervision as outlined in residents' care plans and assessments. Observations revealed that several residents who required supervision and the use of smoking aprons while smoking were not provided these aprons during supervised smoking times, despite the aprons being available on the patio. Staff responsible for supervising residents during smoking sessions were unable to identify all residents by name and did not consistently offer or provide the required safety equipment. Additionally, some residents were observed keeping smoking materials, such as cigarettes and lighters, on their person or in their rooms, contrary to facility policy that required these items to be stored in a designated area. Record reviews indicated that the facility did not conduct smoking safety assessments at least quarterly or as needed for several residents, as required by its own policy. For example, some residents had not received updated smoking evaluations for several months, despite changes in their condition or care needs. Care plans for these residents documented the need for supervision and the use of safety devices due to physical or cognitive impairments, but these interventions were not consistently implemented. Residents with diagnoses such as stroke, hemiplegia, cancer, seizure disorder, and cognitive impairment were among those affected by the lack of proper assessment and supervision. Interviews with staff and residents confirmed that the required safety measures were not being followed. Staff members supervising the smoking area were not always aware of which residents required specific interventions, and residents reported not being offered smoking aprons during smoking times. Some residents admitted to keeping smoking materials with them, and staff acknowledged that policy violations were addressed only when observed. These failures resulted in the facility not adhering to its own smoking safety policies and not providing adequate supervision and safety devices to prevent accidents among residents who smoke.
Failure to Obtain Timely Urology Consultation for Resident with Recurrent UTIs
Penalty
Summary
The facility failed to obtain a timely urology consultation for a resident with significant medical conditions, including quadriplegia, paraplegia, neuromuscular dysfunction of the bladder, and an indwelling Foley catheter. The resident experienced multiple urinary tract infections (UTIs), including infections with Extended Spectrum Beta-Lactamase (ESBL) producing bacteria and Proteus Mirabilis, and was treated with antibiotics on more than one occasion. Despite physician and nurse practitioner documentation indicating the need for a urology consult, there was no evidence in the progress notes that a urologist consultation was requested or completed. Interviews with the resident and staff confirmed that the resident had not seen a urologist and was not informed of any scheduled appointment. The resident expressed awareness that a consult had been ordered but was unaware of any follow-up or arrangements for transportation, which he required due to his physical limitations. Staff interviews revealed uncertainty about whether a consult had been requested, and the Assistant Director of Nursing was unable to provide documentation of a urology consult by the end of the survey.
Failure to Enforce Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to follow physician-ordered fluid restrictions for a resident with multiple medical diagnoses, including renal insufficiency, coronary artery disease, and a history of urinary retention requiring a Foley catheter. The resident had a documented fluid restriction order limiting intake to 2 liters per 24 hours, with specific allocations for dietary and nursing staff. The care plan reflected these restrictions and included interventions to monitor and educate the resident regarding fluid intake. Despite these orders, observations revealed that the resident consistently had access to large cups of water at the bedside, which were refreshed regularly, and the resident reported being able to drink as much water as desired. Interviews with staff indicated a lack of awareness regarding the resident's fluid restriction, with a CNA stating they were not informed of the restriction and routinely provided additional fluids, especially in hot weather. The Assistant Director of Nursing confirmed the presence of the fluid restriction order and the rationale for its implementation following a recent hospitalization for urinary retention and altered mental status. The failure to communicate and enforce the fluid restriction order resulted in the resident having unrestricted access to fluids, contrary to physician orders and the resident's care plan.
Failure to Monitor and Document Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to adequately monitor and document behaviors and side effects for residents receiving psychotropic medications, as required by both facility policy and physician orders. For three out of five sampled residents, there were multiple instances where behavior and side effect monitoring was not documented on the required flow sheets or medication administration records. This lack of documentation occurred despite clear orders and care plan interventions that specified monitoring and reporting of any changes in mood, behavior, or side effects related to psychotropic medication use. One resident with severe cognitive impairment and multiple psychiatric diagnoses had several shifts with missing documentation of behavior and side effect monitoring, even though orders required this to be completed every shift. Another resident, who was cognitively intact and prescribed antidepressants, also had several days in which there was no documented evidence of medication management or monitoring for side effects. A third resident, with diagnoses including anxiety and depression, had missing documentation for anti-anxiety intervention codes and behavior monitoring on several shifts, despite being prescribed both antidepressant and anti-anxiety medications. Interviews with nursing staff and the Assistant Director of Nursing confirmed that the expectation was to monitor and document behaviors and side effects for all residents on psychotropic medications every shift. However, staff acknowledged that there were multiple instances where this documentation was not completed as required. The failure to consistently monitor and document these parameters represents a deficiency in ensuring that residents' drug regimens are free from unnecessary drugs and that adverse effects are promptly identified and addressed.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Documentation Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 18.75% during a medication pass, as six errors were identified out of 32 opportunities. The errors involved two residents and were discovered through direct observation, interviews, and record reviews. The facility's policy defines a medication error as any preparation or administration of drugs not in accordance with physician's orders, manufacturer specifications, or accepted professional standards. For one resident with diagnoses including protein-calorie malnutrition, dementia, and sepsis, the physician's order specified Florastor Oral Capsule 250 mg (Saccharomyces boulardii) for digestive health, which was discontinued on a certain date. However, during a medication pass, an LPN administered Lactobacillus 250 mg instead, despite there being no current order for this medication. Both the LPN and the Assistant Director of Nursing initially stated that the two medications were the same, but later clarified that they are similar but not identical. Another resident with chronic obstructive pulmonary disease, malignant neoplasm, major depressive disorder, and hypertension was observed receiving multiple medications late. The LPN administered the medications after the scheduled time but documented them as given at the scheduled time on the Medication Administration Record (MAR), without noting the actual time or the reason for the delay. The facility's policy requires documentation of late administration and the reason, but this was not followed. The Assistant Director of Nursing confirmed that such documentation was not being completed, and there were no progress notes explaining the late administration.
Failure to Maintain Timely Physician Visit Documentation in Resident Records
Penalty
Summary
The facility failed to ensure that physician visit notes were made part of the resident's medical record, as required by accepted professional standards. A resident with a diagnosis of hypertension, who was cognitively intact, reported not having seen the attending physician during her approximately three-month stay and had only been seen by the APRN. Clinical record review confirmed that there was no documented evidence of the attending physician's visits in the resident's medical record, despite multiple visits by the APRN. The resident expressed concerns about her medical condition, specifically discoloration in her legs, and reported dissatisfaction with the response from facility staff. Interviews with facility staff revealed uncertainty regarding the frequency and documentation of physician visits. The attending physician admitted to using his own EMR system and acknowledged that he had not uploaded visit notes to the facility's system for about a year, citing being busy as the reason for the delay. The lack of timely and proper documentation of physician visits in the resident's medical record constituted a failure to safeguard resident-identifiable information and maintain accurate medical records in accordance with professional standards.
Failure to Implement Infection Control Program and Adhere to CDC Guidelines
Penalty
Summary
The facility failed to implement its Infection Prevention and Control program according to CDC guidelines and its own policies. In one instance, a resident under Enhanced Barrier Precautions (EBP) was not properly identified by staff, and staff members did not consistently perform hand hygiene or use required personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. Staff members were observed entering the resident's room, transferring the resident, and changing bed linens without following EBP protocols, and some staff were unaware of the resident's EBP status or the correct procedures to follow. Additionally, the facility did not ensure proper disinfection of resident-care equipment. During a medication pass, an LPN used a vital signs cart and associated devices, such as a blood pressure cuff and pulse oximeter, without disinfecting them before or after use. The LPN also failed to observe the required drying time for disinfectant wipes, and staff interviews revealed a lack of knowledge regarding the specific disinfectants used and their proper application, including drying times. The facility also failed to maintain urinary catheter drainage bags off the floor for two residents with catheters. Observations showed that the drainage bags were repeatedly found lying on the floor, and staff did not correct this during care. Interviews with staff confirmed awareness that catheter bags should not be placed on the floor, yet the deficiency persisted across multiple observations.
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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.
Illustrative
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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) |
|---|---|---|---|---|
| Medicana Nursing And Rehab Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Lake Worth Rehabilitation Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Finnish-american Village | 1.2 mi | ★★★★★ | 0 | 0 |
| Avante At Lake Worth, Inc. | 2 mi | ★★★★★ | 6 | 1 |
| Vi At Lakeside Village | 2.1 mi | ★★★★★ | 5 | 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.