Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Willowbrooke Court At St Andrews Estates during CMS and state inspections, most recent first.
The facility failed to follow food safety standards by storing raw chicken and Mighty Shakes in the refrigerator beyond recommended time frames. The DCS incorrectly believed the chicken was safe for a week and that it was Cryovac packaged, which was not true. Additionally, Mighty Shakes were stored for a month, exceeding the 14-day limit after removal from the freezer. This affected 42 of 44 residents on oral diets.
The facility failed to maintain accurate records for controlled drugs for a resident, with discrepancies found in the documentation of medication administration. Despite staff describing the correct procedure, the records did not reflect the administration of the medication as required by the facility's policy.
The facility failed to secure medication and treatment carts and improperly disposed of medications. An LPN left a treatment cart unlocked and unattended, and a medication cart was found unsecured on a hallway. An RN left medications unattended during administration and improperly discarded crushed medications in the garbage instead of using the Drug Disposal bottle.
A facility failed to ensure proper feeding tube management for a resident with severe mental status, as an LPN did not verify tube placement before feeding. Additionally, an RN did not adhere to medication administration standards, relying on memory instead of verifying the MAR. The DON and Administrator acknowledged these deficiencies, noting issues with staff orientation.
A resident with severe cognitive impairment and requiring tube feeding was not provided appropriate care to prevent feeding complications. An LPN connected the feeding tube without verifying its placement or patency, contrary to facility policy. The resident's care plan emphasized the importance of these checks to prevent complications, but they were not performed as required.
A registered nurse (RN) at a facility failed to follow proper medication administration procedures, as observed during a survey. The RN, who had recently transitioned from an LPN, crushed medications and left them unattended in a cart drawer while retrieving necessary items and resolving computer access issues. The RN admitted to not having the MAR on hand and relied on memory and prior access from another computer. The facility's DON and Administrator acknowledged the RN's incomplete orientation and the need for further training.
A facility failed to maintain accurate records for controlled drugs, as evidenced by discrepancies in the documentation for a resident's medication. The facility's policy requires that each dose be documented on both the control sheet and eMAR, but records showed missing entries for administered doses. Interviews with staff confirmed the process, yet the records were incomplete, indicating a failure to follow protocol.
The facility failed to monitor and document the behaviors of two residents as per physician's orders, leading to a deficiency in ensuring drug regimens are free from unnecessary drugs. Despite having orders to monitor specific behaviors and document interventions, the facility's records lacked the necessary documentation, which was confirmed by the DON during a review.
The facility failed to secure medication and treatment carts and improperly disposed of medications. An LPN left a treatment cart unlocked and unattended, and a med cart was found unsecured on a hallway. An RN left dispensed medications unattended and disposed of crushed medications improperly, contrary to facility policy.
The facility failed to follow proper infection control and hygiene practices during medication administration and resident care. An LPN did not wear a gown while connecting a feeding tube for a resident on Enhanced Barrier Precautions, and an RN did not perform hand hygiene during medication administration. These actions were contrary to the facility's policies, leading to deficiencies in infection prevention and control.
The facility was found deficient in ensuring that bathrooms were equipped with a functioning resident call system. Observations showed that emergency pull cords in four bathrooms were wrapped around grab bars, making them inoperable. The Maintenance Technician acknowledged the issue and stated that regular checks would be conducted to prevent this problem.
The facility failed to maintain egress doors with delayed egress locking arrangements as per NFPA 101 standards. During a tour, it was observed that the delayed egress doors in the Coconut Grove hallway did not open when tested. The Director of Property Management and the Administrator acknowledged the findings during an interview.
The facility failed to maintain its HVAC system as per NFPA 101 standards, with non-operational exhaust fans in soiled utility rooms in both the east wing of Pineapple Trail and the west wing of Lakeshore. The deficiency was observed during a facility tour with the Director of Property Management, and acknowledged by the Administrator.
The facility failed to maintain documentation for two generator monthly conductance tests, as required by NFPA 99 standards. This deficiency was identified during a record review with the Director of Property Management, and acknowledged by the Administrator and Director of Property Management.
Improper Food Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by improper storage of raw chicken and Mighty Shakes in the refrigerator beyond recommended time frames. During an inspection, it was observed that a box of boneless, skinless chicken was stored in the refrigerator for six days, exceeding the USFDA's recommended storage time for raw chicken. The Director of Culinary Services (DCS) incorrectly believed that the chicken was safe for use for about one week and that it was packaged with Cryovac, which was not the case. Additionally, a box of Mighty Shakes was found in the refrigerator with a date indicating it had been received from the vendor about a month prior. The DCS and Staff B were unaware that the Mighty Shakes should be used within 14 days after being removed from the freezer. The surveyor informed them of the correct storage guidelines, which were confirmed by the facility's sales representative. The DCS relied on information from the distributor, which stated that the chicken had a shelf life of 16 days, but this did not specify refrigeration or freezing conditions. The surveyor clarified that the chicken was not packaged with a low-oxygen method, as initially claimed by the DCS. The facility's failure to follow proper food safety standards had the potential to affect 42 of 44 residents on oral diets.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: The box of chicken and mighty shake was discarded. Identification of other residents potentially affected: Current residents have the potential to be affected; however, based on inspection and not using the chicken or mighty shake no residents were affected. Measures: On re-education provided by the Director of Culinary Services to the culinary team members on following the standards of professional practice for food safety. Following the culinary services policy and procedures food storage chart for dry food and refrigerated storage. New team members will be educated to follow the standards of professional practice for food safety upon hire. Monitoring: The Director of Culinary Services/Executive Chef will complete daily audits for 4 weeks and then weekly for 2 months to ensure all items are following the professional practice for food safety. The Director of Culinary Services will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 3 months or until the committee determines substantial compliance.
Failure in Controlled Drug Record-Keeping
Penalty
Summary
The facility failed to maintain an accurate system of records for the receipt and disposition of controlled drugs, specifically for one resident. The facility's policy on controlled substances management requires strict handling, storage, disposal, and record-keeping, including signing off each dose on the control sheet and electronic medication administration record (eMAR). However, a review of the records for a resident revealed discrepancies in the documentation of controlled medication administration. Specifically, there was no documentation on the eMAR for doses of a controlled medication that were removed from the supply at 1:30 AM and 7:00 AM on a particular day. Interviews with nursing staff revealed inconsistencies in the process of documenting the administration of controlled medications. A registered nurse and a licensed practical nurse both described the procedure of removing medication, marking it on the control sheet, and signing it off on the MAR once administered. Despite this, the records for the resident in question did not reflect the administration of the medication as per the facility's policy, indicating a failure in the system of record-keeping for controlled substances.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation, the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: On resident #4, screening completed, resident's level was noted to be at zero. On licensed nurses were re-educated by the Director of Nursing on the importance of ensuring all medication administrations are signed off in pharmacy log and on Medication Administration Record (MAR) in Point Click Care for accurate account of controlled medications. Identification of other residents potentially affected: Quality review audit of completed. Current residents have the potential to be affected; resident #4 was not affected. Measures: On licensed nurses were re-educated by the Director of Nursing on the importance of ensuring all medications administration are signed off in pharmacy log and on Medication Administration Record (MAR) in Point Click Care for accurate account of controlled medications. In-services/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits during clinical meeting for 4 weeks and then weekly x 3 months to ensure records are in order and that an account of all controlled drugs is maintained and reconciled. Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 4 months or until the committee determines substantial compliance.
Medication and Treatment Cart Security and Disposal Deficiencies
Penalty
Summary
The facility failed to secure medication and treatment carts, as well as properly dispose of medications, during observations conducted by surveyors. An unlocked and unattended treatment cart, identified as the Pineapple treatment cart, was observed next to the East Reception Desk containing several prescription medications. A Licensed Practical Nurse (LPN) acknowledged the cart was left unlocked and unattended, contrary to the facility's policy that requires all medications and biologicals to be securely stored in locked cabinets or carts. Additionally, an unsecured and unattended medication cart was found on the Oasis hallway during an environmental tour with the Administrator and Maintenance Tech, who immediately called for the nurse responsible. During a medication administration observation, a Registered Nurse (RN) left dispensed medications unattended on top of a medication cart while she walked across the hallway to use a wall sanitizer dispenser. The RN also improperly disposed of crushed medications by discarding them in the garbage container attached to the medication cart, instead of using the designated Drug Disposal bottle. These actions were not in compliance with the facility's policy for medication storage and disposal, which requires medications to be disposed of in a manner that ensures accurate reconciliation and security.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: Carts were locked immediately. Re-education was provided to the licensed nurse assigned to east wing to ensure treatment and medication carts are kept locked and secure. Identification of other residents potentially affected: Current residents have the potential to be affected; no other resident was affected. Measures: On re-education initiated to licensed nurses by the Director of Nursing on proper storage of drugs and biologicals. Keeping treatment and medication carts locked and secured. In-service/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits for 4 weeks and then weekly x two months to ensure proper storage of drugs and biologicals and keeping treatment and medication carts locked and secured. The Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 3 months or until the committee determines substantial compliance.
Deficiencies in Feeding Tube Management and Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of feeding for a resident who was admitted with several medical conditions, including a severe mental status. The resident had specific physician orders for feeding tube management, which included checking tube placement before feeding or medication administration, and ensuring the tube's patency. However, during an observation, a Licensed Practical Nurse (LPN) connected the feeding tube without verifying its placement or patency, contrary to the facility's policy and the resident's care plan. Additionally, the facility did not ensure that all nursing staff met professional standards of quality and competency. During a medication administration observation, a Registered Nurse (RN) was found to have crushed medications and stored them in a medication cart drawer without having the necessary equipment, such as a laptop, to verify the medication administration record (MAR) at the time. The RN admitted to relying on her memory and previous access to the MAR on another computer, which was not in line with the facility's standards for medication administration. The Director of Nursing (DON) and the Administrator acknowledged the deficiencies, noting that the RN was new to the facility and had not completed the required orientation checklist for professional staff. The Administrator expressed concern over the RN's preparedness and the inconsistency in the orientation process, which was previously managed by an Assistant Director of Nursing who had been terminated for inconsistent work performance.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation, the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: Resident #43 was assessed by the Director of Nursing for signs of feeding intolerance, placement, and residual. Resident #43 was tolerating feeding okay, placement was confirmed with no residual. On re-education on feeding administration was immediately provided to staff A, the licensed Practical Nurse. Identification of other residents potentially affected: Current residents have the potential to be affected; however, based on the residents' assessment and observation completed, no resident was affected. Measures: Staff A was provided with competency skills training on Feeding Administration by the Director of Nursing. a. Verifying the five rights of administration b. Safety & Proper Positioning c. Tube Placement d. Residual e. Flush f. Control On Relias training was completed by staff A on feeding. Inservice/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits for 4 weeks and then weekly for 2 months to ensure licensed nurses follow the policy and procedure and provide appropriate treatment and services to prevent complications of feeding. The Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly for 3 months or until the committee determines substantial compliance.
Failure to Verify Feeding Tube Placement
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of feeding for a resident who was reviewed for feeding management. The resident, identified as Resident #43, was admitted with several diagnoses, including severe cognitive impairment, and required tube feeding for nutrition and hydration. The facility's policy required checking the placement and patency of the feeding tube before each feeding or medication administration. However, during an observation, a Licensed Practical Nurse (LPN) connected the feeding tube to the resident without verifying the tube's placement or patency, contrary to the facility's policy. The resident's care plan highlighted the risk of complications due to the tube feeding status and included specific interventions to mitigate these risks, such as checking tube placement and providing flushes as ordered by the medical doctor. Despite these directives, the LPN did not perform the necessary checks before initiating the feeding, which could potentially lead to complications. The LPN later stated that she had checked the tube between 12:00 PM and 1:00 PM during medication administration, but this did not align with the requirement to check before each feeding connection.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: On resident #43 was assessed by the Director of Nursing, for signs of feeding intolerance, placement and residual. Resident #43 was tolerating feeding ok, placement was confirmed with no residual. On , Re-education on feeding administration was immediately provided to staff A, the licensed Practical Nurse. Identification of other residents potentially affected: Current residents have the potential to be affected; however, based on the residents assessment and observation completed, no resident was affected. Measures: On staff A was provided with competency skills training on Feeding Administration by the Director of Nursing. a. Verifying the five rights of administration b. Safety & Proper Positioning c. Tube Placement d. Residual e. Flush f. Control On , Relias training was completed by staff A, on feeding. Inservice/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits for 4 weeks and then weekly x 2 months to ensure licensed nurses follow the policy and procedure for and provide appropriate treatment and services to prevent complications of feeding. The Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 3 months or until the committee determines substantial compliance.
Deficiency in Medication Administration Process
Penalty
Summary
The facility failed to ensure that all nursing staff adhered to professional standards of quality during medication administration, as evidenced by the actions of one registered nurse (RN), Staff D. During a medication administration observation, Staff D was seen crushing medications and storing them in the top drawer of a medication cart without having the necessary apple sauce to administer them. She left the cart to retrieve the apple sauce and a laptop computer, which she needed to access the Medication Administration Record (MAR). Upon returning, she was unable to log into the laptop and left again to resolve the issue, leaving the medications unattended for several minutes. Staff D, who had been working at the facility for a month and had recently transitioned from a Licensed Practical Nurse (LPN) to an RN, admitted to the surveyor that she would discard the crushed medications because the resident was not in their room. She also revealed that she had accessed the MAR on another computer located at the nurses' station, rather than having it available on the medication cart as per facility standards. Staff D mentioned that the laptop she was using often gave her problems, and although management was aware, the issue persisted. The Director of Nursing (DON) expressed concern over the incident, noting that medication administration procedures had been recently reviewed and that Staff D was a new nurse. The facility's Administrator confirmed that Staff D had not completed the Orientation Checklist for Professional Staff, which was the responsibility of the Assistant Director of Nursing (ADON), who had been terminated for inconsistent work. A review of Staff D's orientation checklist indicated that she required further education on preparing and organizing for medication administration.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: Staff D, the Registered Nurse, was immediately pulled from the assignment. On staff D was re-educated by the Director of Nursing on medication administration and management to ensure safe and efficient administration of medications to residents. Dispensing, dose preparation and follow the correct medication administration guidelines. Specific competencies and skill set necessary to provide nursing and related services to meet the residents' needs safely. Identification of other residents potentially affected: Current residents have the potential to be affected; however, based on the resident assessment and observation completed, no resident was affected. Measures: On staff D was provided with competency skills training by the Director of Nursing to ensure staff D possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely. a. Verifying the five rights of administration: right person, medication, route, time, and dose. b. Prepare: Place medication in cup, if medication needs to be or can be crushed. c. Control: Perform hygiene. Use control measures and standard precautions. d. Administration. e. Documentation. On , licensed nurses were re-educated by the Director of Nursing on medication administration and management to ensure safe and efficient administration of medications to residents. Dispensing, dose preparation and follow the correct medication administration guidelines. Specific competencies and skill set necessary to provide nursing and related services to meet the residents' needs safely. Training and orientation competency skills will be completed for newly hired licensed nurses. On , Relias training on medication administration and management was completed by staff D, registered nurse. On , staff D and completed 1:1 training with senior registered nurse to ensure medication administration processes are followed. Monitoring: The Director of Nursing/nursing team will complete daily audits for 4 weeks and then weekly audits x 3 months to ensure licensed nurses are following the medication administration process and possess competency skill sets to provide nursing and related services to meet residents' needs safely. The Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly x 4 months or until the committee determines substantial compliance.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to maintain a comprehensive system of records for the receipt and disposition of controlled drugs, which is necessary for accurate reconciliation. This deficiency was identified during a review of records for a resident who was prescribed controlled medications. The facility's policy on controlled substances requires that each dose administered be documented on both the control sheet and the electronic medication administration record (eMAR). However, discrepancies were found in the documentation for a resident who had been prescribed a 50 mg oral tablet to be taken as needed. Specifically, the controlled medication utilization record indicated that tablets were removed at specific times, but there was no corresponding documentation in the medication administration record for those times. Interviews with facility staff, including a registered nurse and a licensed practical nurse, revealed that the process for handling controlled medications involves removing the medication, marking it on the control sheet, and signing it off on the MAR once administered. Despite this procedure, the records for the resident in question were incomplete, indicating a failure to adhere to the established protocol. This lapse in documentation and record-keeping for controlled substances was observed for one of the five sampled residents, highlighting a significant oversight in the facility's pharmacy services.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: On resident #4 screening completed, residents, level was noted to be at zero. On licensed nurses were re-educated by the Director of Nursing on the importance of ensuring medication administrations are signed off in pharmacy log and on Medication Administration Record (MAR) in Point Click Care for accurate account of controlled medications. Identification of other residents potentially affected: Quality review audit of completed. Current residents have the potential to be affected; resident #4 was not affected. Measures: On , licensed nurses were re-educated by the Director of Nursing on the importance of ensuring all medications administration are signed off in pharmacy log and on Medication Administration Record (MAR) in Point Click Care for accurate account of controlled medications. In-services/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits during clinical meeting for 4 weeks and then weekly x 3 months to ensure records are in order and that an account of all controlled drugs is maintained and reconciled. Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 4 months or until the committee determines substantial compliance.
Failure to Monitor and Document Resident Behaviors
Penalty
Summary
The facility failed to adequately monitor and document the behaviors of two residents, leading to a deficiency in compliance with the requirement that each resident's drug regimen must be free from unnecessary drugs. Resident #7, who was admitted with severe cognitive impairment, had a physician's order to monitor specific behaviors and document interventions. However, there were instances where behaviors were observed, but no intervention codes or detailed documentation were recorded in the nursing progress notes or Medication Administration Record (MAR). Similarly, Resident #23, also with severe cognitive impairment, had a physician's order to monitor behaviors and document interventions using specific codes. The MAR showed check marks instead of the required 'Yes' or 'No' to indicate the presence of symptoms, and there was a lack of documentation in the progress notes regarding the resident's behavior and the interventions implemented. This lack of documentation and adherence to physician's orders was acknowledged by the Director of Nursing during a review of the residents' records. Interviews with staff, including a Licensed Practical Nurse and a Registered Nurse, revealed that while there was an understanding of the need to monitor and document behaviors, the actual practice did not align with the facility's policy or the physician's orders. The Director of Nursing confirmed the deficiency in documentation, which contributed to the facility's failure to meet the regulatory requirement of ensuring residents' drug regimens are free from unnecessary drugs.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation, the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: On __, residents #7 and #23 clinical charts were reviewed. Licensed nurses were re-educated on following physicians orders for monitoring of behavior and documentation of intervention codes. Identification of other residents potentially affected: Quality review audit of current residents at risk for behavioral monitoring and interventions was completed. No other residents were affected. Measures: On re-education initiated to licensed nurses by the Director of Nursing on following physician orders for monitoring of behavior and documentation of intervention codes. In-service/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits during clinical meeting for 4 weeks and then weekly x 3 months to ensure physicians orders are being followed for behavior monitoring and documentation to ensure the appropriate treatment and or behavioral interventions are being used to meet the needs of the residents. Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 4 months or until the committee determines substantial compliance.
Medication and Treatment Cart Security Lapses
Penalty
Summary
The facility failed to secure medication and treatment carts, as well as properly dispose of medications, during observations conducted by surveyors. An unlocked and unattended treatment cart, identified as the Pineapple treatment cart, was found next to the East Reception Desk containing several prescription medications. A Licensed Practical Nurse (LPN) acknowledged the cart was left unlocked and unattended, contrary to facility policy which requires all medications and biologicals to be securely stored in locked cabinets or carts. Additionally, during an environmental tour, an unsecured and unattended medication cart was observed on the Oasis hallway. The Administrator had to call for the nurse to address the issue. Furthermore, during a medication administration observation, a Registered Nurse (RN) left dispensed medications unattended on top of a medication cart while she walked across the hallway to use a wall sanitizer dispenser. The RN also improperly disposed of crushed medications in a garbage container attached to the medication cart, instead of using the designated Drug Disposal bottle, as per facility policy.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: Carts were locked immediately. Re-education was provided to the licensed nurse assigned to east wing to ensure treatment and medication carts are kept locked and secure. Identification of other residents potentially affected: Current residents have the potential to be affected; no other resident was affected. Measures: On , re-education initiated to licensed nurses by the Director of Nursing on proper storage of drugs and biologicals. Keeping treatment and medication carts locked and secured. In-service/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits for 4 weeks and then weekly x two months to ensure proper storage of drugs and biologicals and keeping treatment and medication carts locked and secured. The Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 3 months or until the committee determines substantial compliance.
Deficiencies in Infection Control and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper hygiene and personal protective equipment (PPE) protocols during medication administration and resident care, leading to deficiencies in infection prevention and control. During an observation, a Licensed Practical Nurse (LPN) did not wear a gown while connecting a resident's feeding tube, despite the resident being on Enhanced Barrier Precautions due to a medical condition. The LPN acknowledged the need for gown and gloves but did not comply, citing the task's simplicity as the reason for not wearing a gown. In another instance, a Registered Nurse (RN) failed to perform hand hygiene during a medication administration process. The RN donned clean gloves without washing hands, crushed medications, and handled a medication capsule without performing hand hygiene between glove changes. This oversight was acknowledged by the RN during an interview, indicating a lapse in following the facility's hygiene protocols. The resident involved in the first incident had a history of medical conditions requiring tube feeding and was at risk for nutritional issues. The facility's policies on isolation precautions and hand hygiene were not followed, as evidenced by the staff's actions during the observations. These deficiencies highlight lapses in the facility's infection prevention and control program, as outlined in their policies.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: A. Staff A and staff D were immediately re-educated on Control practices. B. Staff A and staff D were re-educated on performing hygiene during care and medication administration and following guidelines for Enhanced Barrier Precautions (EBP) by wearing appropriate Personal Protective Equipment (PPE) during high-contact resident care activities. Identification of other residents potentially affected: Quality Review audit related to control practices was completed. Any issues identified were addressed at that time. No other resident was affected. Measures: On licensed nurses were re-educated on the 5 moments of Hygiene. a. Before patient contact. b. Before a task. c. After exposure risk. d. After patient contact. e. After contact with patient surroundings. Education on control practices and programs have been provided. Handwashing with return demonstration completed for current team members. Re-educated current team members on performing hygiene during care and medication administration and following guidelines for Enhanced Barrier Precautions (EBP) by wearing appropriate Personal Protective Equipment (PPE) during high-contact resident care activities. Prevention and control training will be completed for newly hired team members. Monitoring: The Director of Nursing/ADON Preventionist will conduct weekly random rounds x twelve weeks to monitor for compliance in control practices including hygiene and wearing appropriate Personal Protective Equipment (PPE) during high-contact resident care. The Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee monthly x 3 months or until the committee determines substantial compliance.
Deficiency in Resident Call System in Bathrooms
Penalty
Summary
The facility failed to ensure that bathrooms were adequately equipped with a functioning resident call system, as required by §483.90(g). Observations revealed that in four out of seventy-three bathrooms, the emergency pull cords were wrapped around grab bars, rendering them inoperable. This issue was identified in bathrooms located next to the Oasis Kitchen, the Social Worker office, and other unspecified locations within the facility. The inability to activate the emergency pull cords was confirmed through multiple observations conducted at different times. During a tour of the facility, both the Maintenance Technician and the Administrator acknowledged the issue with the emergency pull cords being wrapped around the grab bars. The Maintenance Technician stated that they would ensure regular rounds are conducted to check the emergency pull cords. However, the report does not mention any corrective actions taken at the time of the observations or any immediate plans to rectify the deficiency.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation, the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: Call system were unwrapped from the grab bar in the residents bathroom immediately. Identification of other residents potentially affected: Current residents have the potential to be affected; however, based on inspection, no residents were affected. Call light strings in residents bathroom were inspected throughout the units to ensure compliance with resident call system. No other resident call system was identified out of compliance. Measures: On [date], team members were re-educated on ensuring the call system cord is not wrapped around a grab bar. The call system must be adequately equipped to allow residents to call for staff assistance through a communication system. Inservice will be completed for newly hired team members. Monitoring: The Director of Property Management and Maintenance Assistants will complete daily audits for 4 weeks and then weekly for two months to ensure compliance with resident call system standards. The Director of Property Management will report the findings to the Quality Assurance Performance Improvement Committee Monthly for 3 months or until the committee determines substantial compliance.
Egress Door Compliance Failure
Penalty
Summary
The facility failed to maintain their egress doors equipped with delayed egress locking arrangements in accordance with NFPA 101 standards. During a facility tour conducted on April 29, 2025, between 1:15 PM and 2:45 PM, it was observed that the delayed egress doors located in the Coconut Grove hallway did not open when tested. This issue was identified in the presence of the Director of Property Management, who was accompanying the surveyors during the inspection. An interview with the Administrator and the Director of Property Management was conducted concurrently with the observations, during which they acknowledged the findings. The deficiency was reviewed with both the Administrator and the Director of Property Management at the exit meeting on the same day at 3:00 PM. The failure to maintain the egress doors in compliance with the NFPA 101 standards was documented as a deficiency, specifically noting the non-compliance with the delayed egress locking arrangements.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. **K222 Egress Doors** Immediate Corrective Action: On 4/29/2025, an emergency purchase order was submitted and service request scheduled for vendor RF Technology to provide service to the egress door located on the west unit adjacent to the Coconut dining room. On 4/30/2025 RF Technology Inc. field service technician repaired the egress door. The door is equipped with delayed egress locking arrangements in accordance with NFPA 101. Identification of other residents potentially affected: All residents have the potential to be affected; however, based on inspection no residents were affected by this deficiency. All egress doors were inspected throughout the units to ensure compliance with NFPA 101 standards. No other egress doors were identified out of compliance. Measures: Director of Property Management and Maintenance team members were re-educated on conducting weekly egress door inspection and document on preventative maintenance sheet and report any non-functioning doors to supervisor immediately. Doors must be equipped with delay egress locking arrangements in accordance with NFPA 101. Monitoring: The Director of Property Management and Maintenance Assistants will complete weekly audits for 4 weeks and then monthly x two months to ensure compliance with NFPA 101 standards. Director of Property management will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 3 months or until committee determines substantial compliance.
HVAC System Deficiency in Soiled Utility Rooms
Penalty
Summary
The facility failed to maintain its Heating, Ventilation, and Air Conditioning (HVAC) system in accordance with NFPA 101 standards. During a facility tour conducted on April 29, 2025, between 1:15 PM and 2:45 PM, it was observed that the exhaust fans in the soiled utility holding rooms located in both the east wing of Pineapple Trail and the west wing of Lakeshore were not operational. These findings were made in the presence of the Director of Property Management. An interview with the Administrator and the Director of Property Management was conducted concurrently with the observations, during which they acknowledged the deficiencies. The findings were reviewed with both the Administrator and the Director of Property Management at the exit meeting on the same day at 3:00 PM. The report cites specific sections of NFPA 101 and NFPA 99 that were not adhered to, indicating a failure to comply with the required standards for HVAC maintenance.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K521 HVAC Immediate Corrective Action: On 4/29/2025, HVAC technician assessed the exhaust fans immediately. A HVAC vendor was contracted to replace the two exhaust fans in soiled utility rooms. Identification of other residents potentially affected: All residents have the potential to be affected; however, based on inspection no residents were affected by this deficiency. HVAC system throughout the units were inspected to ensure compliance with NFPA 101 (2012 edition) and NFPA 99 (2012 edition) standards. No other HVAC system was identified out of compliance. Measures: Director of Property management and Maintenance assistance were re-educated on maintaining HVAC system by ensuring exhaust fans are inspected weekly, documented on preventative maintenance sheet and report any non-functioning HVAC system to supervisor immediately. Exhaust fans in biohazard rooms are required to be functioning to ensure ventilation to manage airborne particles and prevent contamination. Monitoring: The Director of Maintenance and Maintenance Assistants will complete weekly audits for 4 weeks and then monthly x two months to ensure in compliance with NFPA 101 (2012 edition) and NFPA 99 (2012 edition) standards. Director of Maintenance will report the findings to the Quality Assurance Performance improvement Committee Monthly X 3 months or until the committee determines substantial compliance.
Failure to Maintain Essential Electrical System Documentation
Penalty
Summary
The facility failed to maintain and test their Essential Electrical System (EES) in accordance with NFPA 99 standards. During a record review conducted on April 29, 2025, between 10:00 AM and 1:00 PM, it was found that there was no documentation available for two of the generator's monthly conductance tests. This lack of documentation was identified during a review with the Director of Property Management. The absence of these records indicates a failure to comply with the required maintenance and testing protocols for the facility's emergency power systems. An interview with the Administrator and the Director of Property Management confirmed the findings, and they acknowledged the deficiency. The review highlighted that the facility did not have the necessary records to demonstrate compliance with the NFPA 99 and NFPA 110 standards, which require regular testing and maintenance of generator sets and associated equipment. The findings were discussed with the facility's management at the exit meeting on the same day.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K918 Electrical Systems- Essential Electric System Maintenance and Testing Immediate Corrective Action: On 4/30/2025, an Ancel BST500 electronic battery tester was purchased to test the generator battery. Identification of other residents potentially affected: All residents have the potential to be affected; however, based on inspection no residents were affected by this deficiency. No other generator was identified out of compliance. Measures: On 04/29/2025 the Director of Property management and maintenance assistance were re-educated on ensuring the generator battery tests are completed monthly by using the electronic battery tester and to record the conductance measurement on the log. On 5/07/2025, TAW Service Representative provided training and education to Director of Property management and maintenance assistance on using the electronic battery system tester to conduct cold cranking amps conductance test and documenting information on the monthly generator test log. Monitoring: The Director of Maintenance and Maintenance Assistants will complete weekly audits for 4 weeks and then monthly x two months to ensure compliance with NFPA 99 (2012 edition) and NFPA 110 (2010 Edition) standards. The Director of Maintenance will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 3 months or until the committee determines substantial compliance.
What surveyors are citing around you — mapped
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Boca Raton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy At Boca Raton Rehabilitation And Nursing Ce | 0.5 mi | ★★★★★ | 0 | 0 |
| Encore At Boca Raton Rehabilitation And Nursing Ce | 1.5 mi | ★★★★★ | 0 | 0 |
| Boca Circle Rehabilitation Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Avante At Boca Raton, Inc. | 1.8 mi | ★★★★★ | 16 | 0 |
| Boca Raton Rehabilitation Center | 2.2 mi | ★★★★★ | 4 | 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.