Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Yamato Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Food Storage and Temperature Control Deficiencies: The facility failed to store and serve food in accordance with professional standards in the main kitchen. Surveyors found expired pudding cups in the walk-in refrigerator, observed a visiting CDM in the food prep area without a facial covering and with substantial facial hair, and noted ice cream served at improper temperatures and partially liquified on residents’ trays. A later revisit found the freezer at about 25 degrees Fahrenheit and a frozen dairy item soft instead of firm.
Failure to evaluate a persistent eye infection: A resident with conjunctivitis reported ongoing symptoms, including discharge and matted eyes, while record review showed the infection persisted in the R eye after initial antibiotic therapy. Documentation noted the L eye resolved but the R eye remained reddened with discharge and discomfort, and the chart lacked documentation of the eye infection's condition during the course of treatment.
Accident hazards were observed in resident rooms when bedside tables and other items were placed on floor mats intended to protect residents from injury if they rolled out of bed. Three residents with documented fall risk and prior falls were involved, including one resident with severe cognitive impairment and two residents with BIMS scores indicating inability to complete the interview. Staff interviews confirmed that the mats should be kept free of objects, yet surveyors repeatedly found tables on the mats during observations.
Incorrect Tube Feeding Water Flushes: Two residents receiving enteral feedings did not have ordered water flushes consistently provided as prescribed. One resident with dysphagia and dementia was observed multiple times with the feeding pump set to 30 mL/hr instead of the ordered 40 mL/hr, and the water bag was labeled the same incorrect rate. Another resident with dementia, dysphagia, and a G-tube had elevated BUN values, but staff involved in dietary review were unaware of the order to evaluate and adjust the flush, and the flush had not been updated as ordered.
Tube Feeding Not Provided as Ordered: A resident with dysphagia and dementia had a physician order for Jevity 1.5 via feeding tube at 50 ml/hr with a total of 1000 ml per 24 hours. Surveyors observed the resident receiving tube feeding from a bottle labeled the prior day with 700 ml remaining, and later observed the resident without tube feeding hanging even though the order specified it should be hung at 2:00 PM.
Failure to Provide and Document PRN Oxygen Use: The facility failed to provide oxygen as ordered and failed to document PRN oxygen use for two residents. One resident with COPD, asthma, and respiratory failure had an order for 3 L via NC PRN, but the TAR was blank and observations showed the concentrator set at varying levels, including above the maximum setting; staff could not locate MAR/TAR documentation. Another resident with multiple chronic conditions, including CVA, ASHD, and sleep apnea, had an order for 2 L PRN, but had no oxygen care plan and no TAR documentation, while observations showed the concentrator set at 2.75 L, 3.0 L, and 2.5 L.
Incomplete dialysis communication documentation was found for two residents receiving HD. One resident with ESRD and dependence on renal dialysis had multiple missing or incomplete post-dialysis entries, while another resident’s dialysis book contained several forms with the dialysis nurse section left blank and no forms scanned into the chart for two months. Staff stated the forms are completed before and after dialysis and scanned into the record, but the missing documentation was not present.
Inaccurate narcotic reconciliation was identified for two residents after review of controlled substance records and MARs. For one resident, an OxyContin entry lacked a clear year, time, and nurse signature, and the MAR did not match the documented administration. For another resident, Tramadol administration times on the narcotic record did not match the MAR entries. The ADON and DON were made aware of the discrepancies, and the ADON could not retrieve the time stamp audit.
Meals were not provided according to resident choices and menu requirements for several residents with dementia and other diagnoses. A resident with a BIMS score of 01 and two residents with BIMS scores of 03 were observed receiving lunch trays without dessert, while another resident whose meal ticket called for finger foods and a 4-ounce Mighty Shake received a tray missing both items. In addition, a tray line observation found turkey portions weighing 1.5 oz instead of the menu-required 2 oz.
Incorrect Mechanical Soft Diets Served: Two residents with physician-ordered mechanical soft diets were served trays that included items not consistent with the facility’s mechanical soft guidelines. One resident received a chocolate chip cookie that was too hard and later had it replaced by an RN, while both residents were observed with large broccoli stems that required considerable force to cut; one resident stated the broccoli was too hard to eat. The DON/rehab staff described mechanical soft as foods that are soft and require little work to chew.
The facility failed to maintain a sanitary and comfortable environment across four residential areas, with issues such as soiled windows, broken fixtures, and overflowing laundry in the Williamsburg Unit, and similar problems in the [NAME] and Cambridge Units. The pantry in the [NAME] Unit had soiled refrigerator gaskets and unlabeled frozen foods. A second tour revealed worn handrails, peeling paint, and damaged doors in the Cambridge Unit, along with soiled vents and discolored ceiling tiles. The [NAME] Unit had similar issues with worn handrails and a damaged pantry door.
The facility failed to maintain food safety and hygiene standards, affecting potentially 153 residents. Observations revealed issues such as a torn refrigerator gasket, peeling paint, exposed foods, an unclean ice cream freezer, and a meal slicer with dried food and grease. Additional problems included improper storage of jackets in the chemical room, soiled employee lockers, and a dish machine with inadequate wash water temperature.
The facility failed to maintain sanitary laundry services and did not adhere to PPE protocols for residents on Enhanced Barrier Precautions. Observations revealed cross-contamination risks in the laundry room and improper PPE use during care for two residents. Staff acknowledged these infection control issues.
The facility failed to respect the dignity and preferences of two residents. One resident, who is visually impaired and dependent on staff for feeding, was served a mixed pureed meal against her usual preference, as confirmed by a regular CNA. Another resident, who expressed a desire to eat in her room, was taken to the dining room by a floating CNA unaware of her preferences. A BIMS assessment indicated cognitive impairment, highlighting a lack of communication and understanding among staff regarding resident needs.
A facility failed to inform a resident's legal guardian about medical care and treatment options, affecting the guardian's ability to make informed decisions. The resident, with mild cognitive impairment, was uncertain about his medical care, including hip surgery and a Foley catheter. Despite staff awareness, there was no documentation that the guardian was informed about the resident's refusal of a urology consult or its postponement until after surgery. The guardian later expressed a desire for a urology consult before surgery, highlighting a communication gap.
Two residents with significant medical conditions were not provided appropriate assistance during meals, leading to inadequate food intake. One resident was left to eat while lying in bed, resulting in spills and no significant intake, while another struggled to eat independently due to the meal tray being out of reach. Both residents' care plans required assistance with eating, which was not provided.
The facility failed to provide adequate wound care and dressing management for three residents, leading to deficiencies in care. A resident with multiple skin conditions did not receive prescribed topical medications, while another with severe cognitive impairment had an undressed skin tear and a strong urine odor in the room. A third resident had undated dressings without a written order, and staff were unaware of the reason for the dressings, indicating a lack of adherence to the facility's protocol for skin tear care.
A resident with a Stage IV pressure ulcer did not receive appropriate care during a dressing change. The WCN failed to place a clean barrier between the resident's skin and contaminated sheets, despite the presence of a bowel movement near the wound. The wound worsened over a week, and the issue was only addressed after surveyor intervention. The WCN and DON acknowledged the oversight.
The facility failed to manage and store medications properly, leading to expired medications and unlabeled opened medications in storage areas. Additionally, pre-poured medications for two residents were improperly stored after being refused, and not discarded as required. Staff acknowledged responsibility for checking expiration dates and labeling opened medications, but these practices were not followed.
The facility's QAPI failed to effectively address repeated deficiencies in maintaining a safe, clean, comfortable environment (F584) and proper food procurement, storage, preparation, and service (F812). These issues have been cited multiple times in past surveys, potentially affecting all 159 residents. The Administrator acknowledged the ongoing deficiencies during the current survey.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. During observation, 24 vanilla pudding cups were found in the walk-in refrigerator with an expiration date of 01/15/26. During a tray-line observation, a visiting CDM was observed in the food preparation area without a facial covering and with substantial facial hair. At the start of the tray line, a 4-ounce cup of ice cream was measured at 23 degrees Fahrenheit instead of the required 0 degrees Fahrenheit or below, and the ice cream was observed melted or partially liquified on residents’ trays as it was being consumed. On a later kitchen revisit, the CDM stated that ice cream was stored in the reach-in freezer, which was observed at approximately 25 degrees Fahrenheit, and a frozen dairy item measured 13 degrees Fahrenheit and was soft rather than firm or frozen to the touch. The Administrator was informed of these findings.
Failure to Evaluate Persistent Eye Infection
Penalty
Summary
The facility failed to appropriately evaluate a resident with a persistent eye infection. Resident #119 was cognitively intact and required substantial to maximum assistance with activities of daily living. The resident had a care plan for antibiotic therapy related to conjunctivitis, with interventions to monitor and document side effects and effectiveness every shift and to observe the right eye for signs of unresolving or worsening infection. The resident stated she had had pink eye for some time, had received antibiotics, and that the infection was spreading from the right eye to both eyes, with her eyes matted closed from discharge. Physician documentation showed the resident was treated for bacterial conjunctivitis with Tobramycin ophthalmic solution to both eyes, and later an acute care progress note documented that the left eye had resolved while the right eye remained reddened with discharge and mild discomfort. The note changed treatment to Erythromycin ophthalmic ointment for persistent bacterial conjunctivitis and directed monitoring for improvement or need for ophthalmology referral if no improvement. Further review of the record did not reveal documentation of the condition of the resident's eye infection, and the resident completed antibiotic treatment for the right eye on 01/11/26. The ADON acknowledged the findings and stated the resident was arranged to see the ophthalmologist the next day, with cultures and antibiotics ordered.
Accident Hazards on Bedside Floor Mats
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards for residents identified as being at risk for falls. The report states that the facility policy identified obstacles in the footpath as an environmental fall risk factor, and surveyors observed floor mats placed beside beds with objects on top of them for multiple residents. Staff interviews confirmed that the mats were intended to protect residents from injury if they rolled out of bed and that nothing should be placed on top of them. Resident #174 had diagnoses including traumatic subarachnoid hemorrhage, cerebral infarction, COPD, and hypertension, and a quarterly MDS showed a BIMS score of 07, indicating severe cognitive impairment. The resident had three fall incidents since admission, and a fall care plan included floor mats on both sides of the bed. During multiple observations, the bedside table and later a garbage can were seen placed on the left-side mat, and the resident was also observed with a liquid supplement bottle on the bedside table that she could reach but could not replace the lid on. Staff G stated the resident was not at risk for falls and initially said nothing should be placed on the mats; the Unit Manager later agreed the table on the mat was a hazard. Resident #52, with Alzheimer disease and anxiety disorder, had a significant change MDS showing a BIMS score of 99 and a care plan identifying fall risk with use of a perimeter mattress and anticipation of needs. The fall log showed four falls. Resident #61, with cerebral atherosclerosis and mood disorder due to a known physiological condition, also had a BIMS score of 99 and a care plan identifying fall risk with similar interventions; the fall log showed two falls. For both residents, surveyors observed a table placed on the floor mat beside the bed on separate occasions, and staff interviews stated that floor mats should be free of objects and are used to protect residents from hitting the floor.
Incorrect Tube Feeding Water Flushes
Penalty
Summary
The facility failed to adjust and ensure correct gastrostomy water flushes were provided to maintain hydration for two residents receiving enteral feedings. One resident had dysphagia and dementia and was ordered to receive water flushes via PEG at 40 mL per hour, but observations on multiple occasions showed the feeding pump water flush set at 30 mL per hour instead. The resident was observed in bed with tube feeding infusing, and the water flush bag was labeled as 30 mL per hour even though the MAR documented 40 mL per hour. An LPN later reviewed the order and confirmed it should have been 40 mL per hour, and the ADON also observed the pump set incorrectly. The second resident had dementia, dysphagia, and a gastrostomy tube, with elevated BUN values documented on lab review. A physician order first directed staff to flush the feeding tube with 50 mL of water every shift, and later an order increased the flush to 75 mL every shift after a dietary evaluation was ordered due to the elevated BUN. During interview, the dietician stated she was not aware of the order to evaluate and adjust the flush, the diet tech also stated she was not aware, and the ARNP indicated she was not aware that the flush had not been adjusted. The record review and interviews showed that the ordered tube flushes were not consistently followed or communicated for either resident. For the first resident, the pump settings and labeled water flush bag did not match the physician order on repeated observations. For the second resident, the chart reflected elevated BUN and orders to evaluate and then increase the flush, but staff involved in the process stated they were unaware of the order changes and the flush had not been adjusted as ordered.
Tube Feeding Not Provided as Ordered
Penalty
Summary
Care and services for tube feeding were not provided as ordered for Resident #89, who had diagnoses of dysphagia and dementia and was admitted with a history of needing enteral nutrition. A physician order dated 06/29/25 directed staff to administer Jevity 1.5 via feeding tube at 50 ml per hour, with a total volume of 1000 ml every 24 hours and to hang the feeding at 2:00 PM and remove it when the total volume was infused. The care plan dated 01/05/2026 identified the resident as requiring enteral feedings and water flushes as ordered due to nothing by mouth status and dysphagia. During observation on 01/20/26 at 10:59 AM, Resident #89 was in bed with tube feeding infusing at 50 ml per hour, and the bottle of formula hanging had a label dated 01/19/26 at 07:40 with 700 ml remaining. During a later observation on 01/20/26 at 1:02 PM, the resident was sitting in a reclining chair and there was no tube feeding hanging on the pole. When the ADON was informed of the observation, she stated that the feeding should have been hung at 2:00 PM and said she would investigate.
Failure to Provide and Document PRN Oxygen Use
Penalty
Summary
The facility failed to provide oxygen as ordered and failed to correctly document oxygen use for 2 residents. The facility policy for Oxygen Administration required verification of the physician’s order and adjustment of the oxygen delivery device to ensure the proper flow was administered. Resident #123 had diagnoses including COPD, asthma, acute and chronic respiratory failure, morbid obesity, diabetes, and hypertension, and had an order for oxygen at 3 L via nasal cannula PRN. The January 2026 TAR was blank for the PRN oxygen order, and progress notes documented oxygen use at 2 L on multiple dates. During observations, the resident was seen using the oxygen concentrator with the flow meter set above the maximum of 5 L, then later at approximately 2.25 L and 2.5 L, while the resident stated the concentrator should be set to 3 L and reported shortness of breath when moving around without oxygen. Staff were unable to locate MAR or TAR documentation for the PRN oxygen use, and the resident denied adjusting the concentrator settings. Resident #190 had diagnoses including cerebral infarction, hypertension, depression, atherosclerotic heart disease, hyperlipidemia, diabetes, Alzheimer’s disease, and sleep apnea, and had an order for oxygen at 2 L PRN. The resident’s care plan contained no oxygen care plan, and the TAR had no documentation of oxygen use. During observations, the resident was seen using the oxygen concentrator via nasal cannula with the flow meter set at approximately 2.75 L, then at 3.0 L, and later at 2.5 L. Staff were unable to provide MAR or TAR documentation for the resident’s PRN oxygen use.
Incomplete Dialysis Communication Documentation
Penalty
Summary
The facility failed to complete dialysis communication sheets between the dialysis center and the facility for 2 residents receiving hemodialysis. Resident #55 had diagnoses of End Stage Renal Disease and dependence on renal dialysis, was cognitively intact with a BIMS score of 15, and had an order for hemodialysis three times weekly. The care plan documented monitoring for signs and symptoms of dialysis complications, vital signs, intake and output, and infection at the access site. Review of the communication sheets showed no post-dialysis documentation completed on one dialysis date, no communication sheets completed for several other dialysis dates, and one form where the facility nurse’s post-dialysis section had not yet been completed when reviewed. Staff stated the forms are completed before dialysis and after the resident returns, and that the dialysis facility also informs the facility by phone after treatment. Resident #119 was documented as cognitively intact and receiving dialysis, and the resident confirmed going to dialysis three days a week. Review of the dialysis book at the nursing station found six dialysis communication forms for January 2026, but four of the six forms did not have the dialysis nurse’s section completed. There were no communication forms in the book for December 2025, and none were scanned into the resident’s electronic record for December 2025 or January 2026. Medical records staff stated she scans the dialysis communication forms into the record and that they should be scanned at least weekly, and she acknowledged the missing forms were not scanned.
Inaccurate narcotic reconciliation for two residents
Penalty
Summary
The facility failed to ensure standards of practice for medication administration were followed for 2 of 5 sampled residents, involving inaccurate narcotic reconciliation for Resident #1 and Resident #45. Facility policy for clinical narcotic count/disposal required the licensed nurse to document the date and time of administration, amount administered, amount remaining, and signature when a Schedule II medication was given. For Resident #1, review of the Medication Monitoring Control Record for OxyContin 1 mg ER showed it was signed as received on 01/09/26, but the record also contained an entry on line #5 showing the medication was administered on 11/17 with no distinguishable year or time, and line #6 showed 11/17 with no year and a crossed-out time, with no nurse signature. The MAR did not show OxyContin 1 mg ER administered on 11/17. For Resident #45, the Medication Monitoring Control Record for Tramadol 50 mg twice daily showed administration entries on 01/19/26 at 7:00 PM, 01/21/26 at 10:00 AM, and 01/22/26 at 10:00 AM, while the MAR documented administration at 9:27 PM, 12:15 PM, and 12:53, respectively. During interview, the ADON and DON were made aware of the discrepancies, and the ADON was unable to retrieve the time stamp audit for the medications reviewed.
Meals Not Provided According to Resident Preferences and Menu Portions
Penalty
Summary
The facility failed to provide meals according to residents’ choices, allergies, and preferences for 4 of 27 sampled residents observed during dining, including residents with significant cognitive impairment. Resident #173 had diagnoses of dementia and anemia and a BIMS score of 01; during lunch observation, the resident’s tray included fish, cooked pasta, cooked zucchini, milk, and bread, but no dessert, while the other residents in the dining room received dessert. Resident #170, with diagnoses of dementia and muscle wasting and a BIMS score of 03, was observed with a lunch tray of fish, cooked pasta, cooked zucchini, soup, and juice, but no dessert. Resident #20, with diagnoses of anemia and dementia and a BIMS score of 03, also received a tray without dessert. Resident #120, diagnosed with dementia and psychosis and noted as rarely understood, had a meal ticket for finger foods and a 4-ounce Mighty Shake, but the tray contained a fish sandwich, cooked zucchini, juice, and milk, and was missing both the dessert and the Mighty Shake; the other residents in the dining room received dessert with lunch. The facility also failed to follow its own menu’s portioning during a tray line observation. The Week 3 Day 19 cycle menu called for 2 ounces of turkey, 2 ounces of gravy, 1/2 cup of peas, bread dressing, and 1/2 cup of ice cream. During the tray line observation, the turkey on a regular diet plate weighed 1.5 ounces instead of the required 2.0 ounces or more. The Cook stated that the turkey pieces had been pre-sliced before cooking and were all weighed over 2 ounces.
Incorrect Mechanical Soft Diets Served
Penalty
Summary
The facility failed to provide the correct mechanical soft therapeutic diet as ordered by the physician for 2 of 2 sampled residents, Resident #128 and Resident #171. The facility’s Diet Manual stated that a mechanical soft diet consists mostly of foods with regular textures that are not hard, sticky, or crunchy, and that foods should be moist and fork-mashable. Resident #128 had diagnoses of Bipolar disorder and Type 2 Diabetes, a mechanical soft texture diet order dated 06/02/25, and a Quarterly MDS showing a BIMS score of 11, indicating moderate cognitive impairment. Resident #171 had diagnoses of Dysphagia and Dementia, a mechanical soft texture diet order dated 5/20/2025, and a Quarterly MDS showing she was rarely understood. During observation, Resident #128 was served a meal tray labeled mechanical soft that included fish, cooked pasta, and a chocolate chip cookie; the cookie was so hard that the surveyor used strong force with a knife to cut through it, and Staff E, RN, later replaced it because it was too hard for the resident. Resident #171 was observed eating a meal tray labeled mechanical soft that included soft meat, cooked potatoes, and large pieces of broccoli stems about 2 inches long; the surveyor used considerable force with a knife to cut through the broccoli stems. In another observation, Resident #128 was served a mechanical soft meal that included chopped meat, roasted potatoes, and large pieces of broccoli stems about 2 inches long, and the resident stated the broccoli stem was too hard to eat. The Director of Rehab stated the facility provides regular, pureed, and mechanical soft diets and that the mechanical soft diet should be soft, require little work, and be easier on mastication.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment across four residential areas, including the Williamsburg Unit, [NAME] Unit, Cambridge Unit, and [NAME] Unit. During an initial environment tour, several deficiencies were observed. In the Williamsburg Unit, the specimen refrigerator in the soiled utility room had a large build-up of ice, which was not being defrosted regularly, potentially affecting lab analysis accuracy. Multiple rooms had visibly soiled windows, and one room had a torn window screen. A hallway light fixture was broken and falling off the wall, and the community shower had a heavily soiled floor and a broken electrical cover. The laundry chute room was overflowing with non-bagged soiled linens, with many on the floor, and the ceiling vent was dust-laden. In the [NAME] Unit, the pantry refrigerator gaskets were heavily soiled with dead insects, and large containers of frozen foods were unlabeled. A second tour revealed further issues in the Cambridge Unit, where hallway handrails and chair rails were heavily worn with peeling paint. The community shower lacked a privacy curtain, had a broken ceiling light cover, and the entry/exit door was worn. The trash/laundry chute room had a soiled ceiling vent and discolored ceiling tiles indicating a roof leak. Several room entry doors were damaged, and windows were heavily soiled. In the [NAME] Unit, hallway handrails and chair rails were similarly worn, and the pantry had a dirt-laden ceiling vent and a damaged door. The lounge/dining room had large holes in window screens and soiled window surfaces.
Food Safety and Hygiene Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting potentially 153 of its 159 residents. During an observation tour, several deficiencies were noted. The walk-in refrigerator had a torn door gasket and peeling paint, with exposed cooked foods, risking contamination. The ice cream freezer had a heavy ice build-up, a soiled door gasket, and lacked a thermometer. The dry goods storage room was unclean, with an employee's soiled jacket on a food cart, an unsecured container of lemonade powder, and peeling paint on the walls. The commercial meal slicer was not properly cleaned, with dried food and grease present. Additional issues included jackets stored in the chemical storage room, risking chemical residue transfer to food. The mop/broom storage room had a dust-laden vent, and employee lockers in the bathroom vestibule were heavily soiled, containing soiled clothing and unidentifiable foods. The high-temperature dish machine's wash water was below the required temperature, compromising sanitation. These observations indicate a significant lapse in maintaining food safety and hygiene standards within the facility.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to maintain safe and sanitary laundry services and did not adhere to proper use of Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions. During a tour of the laundry room, it was observed that laundry bags were on the floor due to an overfilled bin, creating a risk of cross-contamination. Additionally, a large bin of dirty laundry was found with its lid askew, and clean laundry bins contained dirt and debris, which could lead to contamination of clean laundry. The Regional Maintenance Director and Administrator acknowledged these issues as infection control problems. The facility also failed to properly implement Enhanced Barrier Precautions for two residents. For one resident, a nurse administered medication via a PEG tube without wearing a gown, despite the presence of a sign indicating Enhanced Barrier Precautions. The nurse admitted to not following the protocol. Similarly, a CNA performed Foley catheter care for another resident without wearing a gown, contrary to the facility's policy. The CNA acknowledged the oversight and the importance of wearing a gown during such procedures.
Failure to Respect Resident Preferences and Dignity
Penalty
Summary
The facility failed to treat residents with respect and dignity, as evidenced by two separate incidents involving Resident #33 and Resident #82. In the first incident, Resident #33, who is visually impaired and dependent on staff for feeding, was served a pureed meal by a CNA (Staff H) who mixed all the pureed foods together, claiming it was the resident's preference. However, another CNA (Staff I) who regularly feeds Resident #33 stated that the resident never requested such a mixture, indicating a lack of consistency and respect for the resident's preferences. The resident's medical history includes ESRD, pneumonia due to inhalation of solids and liquids, dysphagia, and diabetes, with a current diet order for a carbohydrate-controlled, high-protein renal pureed diet. Despite the surveyor's request for a new tray, the mixed meal was fed to the resident, highlighting a disregard for the resident's dignity and dietary needs. In the second incident, Resident #82, who is dependent on assistance for feeding, expressed a preference to eat in her room rather than the dining room. However, a floating CNA (Staff B) took the resident to the dining room, citing a lack of knowledge about the resident's usual dining preferences and deferring to the nurse for clarification. The Unit Manager (Staff C) confirmed that Resident #82 typically eats lunch in the dining room unless she refuses or is unable to go, but noted that the resident is not cognitively able to express her preferences consistently. A BIMS assessment conducted by the social worker (Staff A) resulted in a score of 6, indicating cognitive impairment. These incidents demonstrate a failure to honor the residents' rights to self-determination and personal preferences, as well as a lack of communication and understanding among staff regarding individual resident needs.
Failure to Inform Guardian of Medical Decisions
Penalty
Summary
The facility failed to inform a resident's legal guardian about proposed medical care and treatment options, affecting the guardian's ability to make informed decisions. The resident, who had mild cognitive impairment, expressed uncertainty about his medical care, specifically regarding hip surgery and the presence of a Foley catheter. The resident was admitted with a Foley catheter due to an ESBL infection and had been on intravenous antibiotics. Despite the resident's cognitive impairment, there was no documentation that the guardian was informed about the resident's refusal of a urology consult or the postponement of the consult until after hip surgery. Interviews with facility staff revealed that the acting Director of Nurses (DON) and the resident's physician were aware of the resident's medical status and decisions. However, the guardian was not informed about the postponement of the urology consult or the resident's refusal of the consult. The guardian later expressed a desire for the resident to see a urologist before the hip surgery, indicating a lack of communication from the facility regarding the resident's care plan.
Failure to Assist Residents with Eating
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the ability of two residents to eat independently. During a breakfast meal observation, Resident #19 was served a meal tray while lying in bed asleep. The Certified Nursing Assistant (CNA) left the tray on the overbed table without attempting to awaken the resident or assist with eating. The resident, who has diagnoses including COPD, Parkinson's Disease, and Dementia, was observed to be very hungry and attempted to eat a frozen supplement and drink juice while lying flat, resulting in spills and no significant intake. The resident's clinical record indicated a significant weight loss over four months and a care plan that required assistance with eating. Another observation involved Resident #28 during a lunch meal, where the CNA placed the meal tray on the overbed table out of the resident's reach and left without providing supervision or assistance. The resident, who has diagnoses including ASHD, Parkinson's Disease, and Dementia, struggled to eat independently, resulting in food spillage and less than 25% meal intake. A subsequent breakfast observation showed similar issues, with the resident unable to reach utensils and spilling food while attempting to eat with hands. The resident's care plan required assistance with eating and positioning upright, which was not provided. Both residents were observed by the facility's Registered Dietitian, who confirmed the surveyor's findings and deemed the issues unacceptable. The lack of assistance and supervision during meals led to inadequate food intake for both residents, despite their care plans indicating the need for assistance with eating.
Inadequate Wound Care and Dressing Management
Penalty
Summary
The facility failed to provide appropriate wound care and dressing changes for three residents, leading to deficiencies in care. Resident #12, who had multiple skin conditions, did not receive the prescribed topical skin medications as per physician orders. Observations revealed undated dressings on the resident's chest and scalp, with the resident expressing that the ointments were not applied as instructed by the dermatologist. The clinical record review showed multiple skin treatments were ordered, but not all were available or applied, as confirmed by the staff. Resident #20, who had severe cognitive impairment, was observed with an uncovered skin tear on the right forearm. The dressing was undated and loose, with serous sanguinolent secretions noted. Despite a physician order for dressing changes, the resident was found with an undressed skin tear, bleeding, and a strong urine odor in the room. Staff interviews revealed a lack of awareness and adherence to the dressing change schedule, contributing to the resident's compromised skin condition. Resident #47, also with severe cognitive impairment, had undated dressings on the right lower leg and elbow. The clinical record lacked a written order for skin dressings, and staff were unaware of the reason for the dressings. Observations and interviews indicated that the facility's protocol for skin tear care was not followed, and the wound care nurse was not informed of the resident's condition. The lack of documentation and communication among staff led to inadequate wound care for the resident.
Deficiency in Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident with a sacral wound, leading to a deficiency. The resident, who was admitted with a Stage IV pressure ulcer and had a severely impaired cognitive status, was observed during a dressing change. The Wound Care Nurse (WCN) did not place a clean barrier between the resident's skin and the contaminated brief and bed sheets, despite the presence of a bowel movement near the wound area. The WCN proceeded with the wound care without cleaning the bowel movement, risking cross-contamination. The resident's sacral wound had worsened over a week, with measurements increasing from 2.2 x 0.6 x 0.1 cm to 2.5 x 1.5 x 0.2 cm. The WCN and the Director of Nursing (DON) acknowledged that a clean barrier should have been used and the resident should have been cleaned before starting the wound care. The bowel movement was only cleaned after surveyor intervention, highlighting the facility's failure to adhere to proper wound care procedures.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications and biologicals, leading to several deficiencies. During a medication storage review, expired medications and tube feeding formulas were found in two of the four medication storage areas. Specifically, expired Aspirin, Bisacodyl, and Osmolite tube feeding formula were discovered in the Cambridge unit, while expired Glucerna tube feeding formula was found in another unit. Additionally, an opened and unlabeled bottle of Milk of Magnesium was noted. Staff members acknowledged that they were responsible for checking expiration dates but failed to do so. Further deficiencies were observed in the handling of opened and unlabeled medications. In the Cambridge treatment cart, an opened, unlabeled, and expired bottle of Hibiclens skin care solution, as well as undated tubes of Hydrocortisone cream and Therahoney gel, were found. Staff admitted that opened bottles and tubes should be dated with an opening date, but this was not done. The Director of Nursing (DON) was informed of these issues, acknowledging the oversight in labeling and dating opened medications. The facility also failed to properly secure medications for two residents. During a medication storage observation, pre-poured and unpackaged medications were found stored in a medication cart for two residents who had refused their morning medications. The medications were not discarded as required, and the DON recognized that the medications should not have been pre-poured and should have been discarded when refused. This oversight in medication management and storage practices highlights significant deficiencies in the facility's adherence to medication safety protocols.
Repeated Deficiencies in Environmental and Food Safety Standards
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Activities (QAPI) failed to effectively implement plans of action to correct identified quality deficiencies. This is evidenced by repeated deficient practices related to F584, which pertains to maintaining a safe, clean, comfortable, and homelike environment, and F812, which involves food procurement, storage, preparation, and service. These deficiencies have been cited multiple times during Recertification and Relicensure surveys, specifically on exit dates in April 2019, January 2021, January 2022, and April 2023 for F584, and in January 2021, January 2022, and April 2023 for F812. The repeated nature of these deficiencies indicates a failure in the facility's QAPI to address and rectify the issues effectively, potentially affecting all 159 residents residing in the facility at the time of the survey. During an interview, the facility's Administrator was informed that these deficiencies would be cited again in the current survey, acknowledging the ongoing issues.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 274 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Boca Raton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avante At Boca Raton, Inc. | 2.5 mi | ★★★★★ | 1 | 0 |
| Boca Raton Rehabilitation Center | 2.6 mi | ★★★★★ | 4 | 0 |
| Abbey Delray South | 3.2 mi | ★★★★★ | 0 | 0 |
| Harbours Edge | 3.3 mi | ★★★★★ | 1 | 0 |
| Cascades Health And Rehabilitation Center | 3.4 mi | ★★★★★ | 6 | 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 October 2026) and official state health department websites.