Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, and interview, the facility failed to follow up on voiced medical concerns for 1 of
1 sampled residents (Resident #36) who voiced concerns to both nursing staff and physician staff, of
possible skin cancer, and requested to be seen by an outside physician for removal of the skin cancers. The
facility failed to follow through with the resident's request.
Residents Affected - Few
The findings included:
During an interview on 11/29/21 at 9:48 AM, Resident #36 was asked if he was receiving the care and
services he expected from the facility. Resident #36 stated he was concerned about the skin cancer on his
right hand and left ear, further explaining that he had had other skin cancers removed previously. Resident
#36 showed the surveyor a prominent growth on the top of his right hand and another on the top of his left
ear. His left ear had an obvious indentation and Resident #36 stated that was where a previous
dermatologist had removed skin cancer. Resident #36 stated he spoke with a lady who he believed was a
Nurse Practitioner about three days ago, who agreed it was skin cancer and walked away. When asked if he
had spoken with any other facility staff about his concerns, Resident #36 stated he spoke with the Unit
Manager about a month ago.
Record review revealed Resident #36 was admitted to the facility on [DATE], with his most current
readmission on [DATE]. Review of the most current Minimum Data Set (MDS) assessment dated [DATE]
documented Resident #36 had a Brief Interview for Mental Status (BIMS) score of 14 on a scale of 0 to 15,
indicating he was alert and oriented. Review of the record lacked any mention of skin cancer or referral to a
dermatologist. Review of the progress notes by the Nurse Practitioner from 11/22/21, 11/24/21, and
11/26/21 all lacked any mention of skin cancer or issues, or any mention of a referral for dermatological
services.
During an interview on 12/01/21 at 9:39 AM, Staff B, a Licensed Practical Nurse (LPN)/Unit Manager stated
she was unaware of any skin issues for Resident #36. The Unit Manager stated she would speak with the
resident and call the VA (Veterans Administration) for an appointment.
On 12/01/21 at 10:08 AM, Resident #36 came up to the nurse's station and spoke to the Unit Manager.
Resident #36 was overheard stating, I told the lady . the Nurse Practitioner, and she said 'yea, those are
skin cancers and walked away.'
During an interview on 12/01/21 at 10:59 AM, Staff G, a Certified Nursing Assistant (CNA) confirmed
Resident #36 was very alert and oriented and was able to make his needs known. When asked if the
resident had a good recall of things, she stated he did.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 9
Event ID:
105485
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105485
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hamlin Place of Boynton Beach
2180 Hypoluxo Road
Lantana, FL 33462
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 12/01/21 at 11:05, Staff H, a Nurse Practitioner, was asked if she was aware of the
skin cancers on the hand and ear of Resident #36. Staff H stated she was not a dermatologist but
confirmed the resident had pointed them out to her recently. The Nurse Practitioner explained the resident
had a lot of sun damage. The Nurse Practitioner stated she told Resident #36 the areas were probably skin
cancers, and he should probably be seen (by a dermatologist) at some point in time. When asked if she
followed up with anyone or told staff at the facility about the voiced concerns from Resident #36, the Nurse
Practitioner stated she had not. The Unit Manager was at the nurse's station during the conversation and
stated she had now called the VA and was awaiting a return call from the resident's social worker. The Unit
Manager agreed the interventions were done after surveyor intervention.
During a subsequent interview on 12/01/21 at 3:30 PM, Resident #36 stated he wanted to clarify
something. The resident stated he never pointed out his skin issues to the Unit Manager. Resident #36
stated the only persons who knew about it were that Nurse Practitioner and another floor nurse, whose
name he could not recall.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105485
If continuation sheet
Page 2 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105485
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hamlin Place of Boynton Beach
2180 Hypoluxo Road
Lantana, FL 33462
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an
observation on 11/30/21 at 2:34 PM, the specialty air mattress for Resident #74 was set on static mode and
at 325 pounds (photographic evidence obtained).
Residents Affected - Few
During a subsequent observation on 12/02/21 at 10:30 AM, the Wound Care Physician was in the room of
Resident #74. An observation of the specialty air mattress revealed it remained on the static mode at 325
pounds. The Wound Care Physician then looked at the specialty air mattress, looked in the record to obtain
resident's weight, and lowered the settings on the specialty air mattress to match his current weight. The
physician stated sometimes the settings get accidentally changed, but confirmed it should be set to the
resident's weight. When asked if the physician would prefer the setting to be on the static or alternating
mode, the physician stated it should be on the alternating mode.
Review of the most current weight for Resident #74 was 154 pounds as of 11/29/21.
Based on observation, interview and record review, the facility failed to provide and maintain specialty air
mattress and ensure proper settings to prevent the worsening of pressure ulcers for 1 of 1 sampled
residents (Resident #74) reviewed for Pressure Ulcers.
The findings included:
Review of the facility policy Pressure Ulcer Preventive Measures revised 04/25/17 documented, 18. For
residents in bed, who are completely immobile, use devices that relieve pressure on the heels, most
commonly by raising the heels off the bed. Use pillows under the length of the lower leg, suspending the
heels. When using a specialty support surface, follow manufacturer's instructions.
Review of the Operation Manual for the Signa Relief Alternating Pressure System with Low Air Loss
specialty air mattress documented, 7.0 Program Settings: 1. Place the patient in the center of the mattress.
Adjust the mattress' internal pressure according to the patient weight by using the weight button on the
control panel of the power unit.
1) Record review revealed Resident #74 was admitted to the facility on [DATE] and most recently
readmitted for current stay on 11/26/21. According the resident's most recent complete assessment, a
Quarterly Minimum Data Set (MDS), completed on 11/08/21, Resident #74 had a Brief Interview for Mental
Status (BIMS) score of 15, indicating 'cognitively intact'. The Assessment documented that Resident #74
was dependent upon staff for all Activities of Daily Living (ADLs). Resident #74's diagnoses at the time of
the assessment included: Malnutrition; Pressure ulcer of sacral region, Stage 4 Pressure ulcer of right
ankle, Stage 3; Pressure ulcer of left heel unstageable; Hemorrhage of anus and rectum; pressure ulcer of
right buttock, unstageable and Pressure ulcer of left buttock unstageable.
An 'admission Evaluation' dated 11/27/21, documented that the resident's pressure ulcers were present
upon re-admission.
Resident's orders included:
[Name of the equipment company] Air Mattress for Wounds to buttocks 11/27/21.
QSM Wound Care Consult for Evaluation and Treatment for open area to right buttock - 11/27/21.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105485
If continuation sheet
Page 3 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105485
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hamlin Place of Boynton Beach
2180 Hypoluxo Road
Lantana, FL 33462
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
The list of Active diagnoses on Resident #74's Baseline Care Plan, dated 11/26/21 (date of readmission),
included: Pressure Ulcer of Right Ankle, Stage 3; Pressure Ulcer of Left Heel, Unstageable; Pressure Ulcer
of Left Ankle, Stage 3; Pressure Ulcer of Sacral Region, Stage 4; Pressure Ulcer of Left Buttock,
Unstageable; Pressure Ulcer of Right Buttock, Unstageable; End Stage Renal Disease; Hemorrhage of
anus and Rectum and Malnutrition. The Baseline Care Plan documented that the resident was dependent
upon staff for all Activities of Daily Living and was 'Always incontinent' of urine and bowel.
A Skin wound note, dated 11/18/21 at 14:07, documented, Resident seen by Wound Physician. Treatment
continued to apply calcium alginate with medi-honey to right buttocks, right ankle, left posterior medial heel,
left posterior medial heel, left lateral ankle, sacrum, right Ischium, and scrotum. No signs of infection noted.
Documentation in the resident's Medication Administration Record (MAR) in the resident's electronic health
record documented Resident #74's compliance with intake of supplement to promote wound healing.
Further review of Resident #74's electronic medical records revealed no documentation of the resident
having or receiving an air mattress per physician's orders.
During an interview, on 11/29/21 at 10:45 AM, with Resident #74, when the resident was asked of any skin
issues, Resident #74 replied, I've got sores on my backside on my rear end and a little on the lower back.
Before I went to the hospital last Friday, I had a air mattress. Since I got back, I don't have the air mattress. I
guess they never put me in it. I used to be in [room #] and that is where the bed is. During the interview, it
was noted that the resident was positioned on a standard mattress at the time of interview, as evidenced by
there not being any controls at the resident's foot of his bed that would control the firmness of the air
mattress, should one had been on the resident's bed.
During a follow up interview, on 11/30/21 at 3:40 PM, with Resident #74, it was noted that there was an air
mattress in place on the resident's bed. When asked about the air mattress, Resident #74 replied, I got it
yesterday, late in the afternoon. Resident #74 further stated that the mattress was comfortable and felt
better
During an interview, on 12/01/21 at 3:11 PM, with Staff A, RN, when asked about Resident #74 having an
air mattress, Staff A replied, He always had an air mattress. Whenever we have a patient transfer, we call
maintenance to get the mattresses and get the room ready and to move the mattress. When he first came
here it was worse (pressure ulcers.) when asked if the resident received an air mattress upon his return
from the hospital into a different room from his previous stay, Staff A was not able to recall.
During an interview, on 12/01/21 at 3:15 PM, with Staff B, LPN/UM, Staff B stated, He came in the middle
of the night on the weekend. The nurses that work on the weekend should have tried to get him one.
Maintenance should have had one in storage.
During an interview, on 12/01/21 at 3:28 PM, with the Maintenance Director, when asked about getting an
air mattress for a resident when ordered, the Maintenance Director stated, I started this job on Monday
(11/22/21). I was here on Saturday and there was nobody asking for an air mattress, (Staff C) was here on
Sunday. The request would have been put into TELLS (maintenance requisition system)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105485
If continuation sheet
Page 4 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105485
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hamlin Place of Boynton Beach
2180 Hypoluxo Road
Lantana, FL 33462
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview, on 12/01/21 at 3:40 PM, with Staff C, Maintenance Assistant, when asked of any
orders for an air mattress for Resident #74, Staff C stated that there were no orders received.
During an interview, on 12/01/21 at 4:29 PM, with Staff D, RN via telephone, when asked about Resident
#74 having an air mattress, Staff D replied, He came after I left, I worked with him on Saturday (11/27/21) I
didn't see an order in his MAR (Medication Administration Record) or TAR (Treatment Administration
Record) for an air mattress. Staff D further stated that a traditional mattress had the potential to worsen the
pressure sores that the resident had.
During an interview, on 12/02/21 at approximately 9:10 AM, with Staff C and Staff E, Maintenance
Assistant, both stated that the facility does not keep air mattresses on site. The Administrator stated that the
facility orders air mattress when needed.
During an interview, on 12/02/21 at 9:42 PM, with Staff F, LPN, via telephone, when asked about Resident
#74 having an air mattress, upon re-admission, Staff F replied, He came in late at night, I know the order
was there. I left that morning at around 730 and was off for the weekend and wasn't in the building again
until Monday night. I assumed that the mattress was delivered. I was not aware. Before he went out, he had
one because of his condition. He had an order for one when he came back, I assumed that they would have
delivered one on Saturday from the company.
During an interview on 12/02/21 at 10:22 AM, with representative from the equipment supply company that
mattresses and equipment are ordered and received, when asked about an order for an air mattress for
Resident #74, the representative replied, there was one ordered on October 25th and the order is still in
place. When asked about the process for ordering an air mattress, the representative stated, Our office is
open 8:00 AM to 7:00 PM and we have a 24-hour answering service so whenever we are closed, one of our
associates will call back right away. When asked about the timing between ordering and receiving an air
mattress, the representative stated, Within 24 hours if not on the same day, depending on the location and
scheduling.
On 12/02/21 at 11:12 AM, the Administrator stated, We have air mattresses on site, we have some that are
our own, we mostly rent, but we have used our own.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105485
If continuation sheet
Page 5 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105485
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hamlin Place of Boynton Beach
2180 Hypoluxo Road
Lantana, FL 33462
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, interview, and policy review, the facility failed to ensure a timely assessment for
removal of an indwelling urinary catheter for 1 of 3 sampled residents reviewed for catheters (Resident
#327).
The findings included:
Review of the policy Indwelling Urinary Catheter Removal Protocol not dated documented two potential
pathways to follow. Either the physician chooses to follow nurse driven removal protocol that is imbedded in
the orders, or the physician will place a discontinue order when the indwelling catheter should be removed
and the nurse will continue to assess catheter necessity daily.
During an observation on 11/30/21 at 2:26 PM, Resident #327 was lying in bed, with an indwelling urinary
catheter noted in use. Further observations revealed clear yellow urine was noted in the tubing. Resident
#327 explained he had been unable to urinate while a patient in the hospital, a bladder scan was done with
800 ml (milliliters) of urine noted in his bladder, so an indwelling catheter was placed. When asked if the
facility had addressed removing the catheter, Resident #327 stated they had not. When asked if he was told
he has or had any type of obstruction, the resident stated he had not.
An observation on 12/01/21 at 9:33 AM revealed Resident #327 still had the indwelling urinary catheter.
Review of the record revealed Resident #327 was admitted to the facility on [DATE]. Review of the current
Minimum Data Set (MDS) assessment dated [DATE] documented Resident #327 had a Brief Interview for
Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was alert and oriented. This
same MDS also documented the resident had an indwelling urinary catheter. Further review of the record
revealed an order dated 11/19/21 for a Foley (indwelling urinary) catheter for obstructive uropathy. The
record lacked any imbedded orders for the nurse driven removal protocol and lacked any daily catheter
necessity assessment, as per their indwelling catheter removal protocol.
Review of the 11/02/21 admission hospital record revealed Resident #327 did have acute kidney failure
during that hospitalization that was resolved. The hospital record lacked any attempt to remove the
indwelling urinary catheter.
During an interview on 12/02/21 at 1:34 PM, Staff B, the Licensed Practical Nurse (LPN)/Unit Manager was
asked about the indwelling catheter for Resident #327. The Unit Manager explained as she was leaving the
facility the previous evening, and she spoke with Resident #327, who did not know why he had the urinary
catheter. The Unit Manager stated the resident told her that he was urinating without any issues prior to his
recent hospitalization. The Unit Manager stated she suggested a voiding trial (removal of the indwelling
urinary catheter with monitoring of urine output), spoke with the restorative nurse, who was responsible for
the voiding trials, and spoke with the Nurse Practitioner who stated he would write an order to discontinue
the Foley and do a voiding trial. The Unit Manager looked in the electronic medical record (EMR) and an
order had not been written as of yet.
Staff I, the Restorative Nurse, joined the conversation at this time. Staff I stated Resident #327
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105485
If continuation sheet
Page 6 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105485
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hamlin Place of Boynton Beach
2180 Hypoluxo Road
Lantana, FL 33462
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
came to the facility with the Foley catheter. The Restorative Nurse stated that today the resident asked why
he had the Foley. The Restorative Nurse stated she spoke with the Nurse Practitioner who said he would
put the order into the EMR. When asked why the possible discontinuation of the indwelling urinary catheter
was not addressed prior to today, the Restorative Nurse stated they were awaiting an MD (physician) order.
The Unit Manager then stated, He never asked to get it (the indwelling catheter) removed.
Residents Affected - Few
During a phone interview on 12/02/21 at approximately 2:00 PM, Staff J, a Nurse Practitioner, was asked
about the indwelling urinary catheter for Resident #327. The Nurse Practitioner stated he had spoken with
the Restorative Nurse that morning and told her to remove the catheter, and that he was waiting on the
nurse to enter the order so that he could sign it. When asked why the possible removal of the indwelling
urinary catheter was not addressed prior to today, the Nurse Practitioner stated he was waiting on the
Infectious Disease physician to clear him. The Nurse Practitioner also stated the urinary volume had not
been good enough and the urine was a little brown last week. The Nurse Practitioner stated he spoke with
the doctor who said to wait (to discontinue the catheter).
Further review of the record lacked any documented evidence the possible removal of the indwelling
urinary catheter was discussed or assessed. Further review of the Nurse Practitioner's progress note dated
11/24/21, the only time the Nurse Practitioner had seen the resident, documented the resident had an
indwelling urinary catheter that was draining clear yellow urine. The note lacked any documentation of
brown or discolored urine or a low urinary output.
During an interview on 12/02/21 at 2:21 PM, Staff K, a Registered Nurse (RN), stated the urine for Resident
#327 had been clear with adequate output throughout his stay.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105485
If continuation sheet
Page 7 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105485
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hamlin Place of Boynton Beach
2180 Hypoluxo Road
Lantana, FL 33462
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, record review, and policy review, the medication error rate was 8 percent.
Two medication errors were identified while observing a total of 25 opportunities, affecting 1 of 6 residents
observed (Resident #38). The RN also failed to follow their policy to ensure the five rights of administration
of medications, by failing to ensure the right resident, and nearly administered the wrong medication.
Residents Affected - Few
The findings included:
Review of the policy Medication Administration - General Guidelines dated April 2018 documented,
Procedures: Preparation . 4. FIVE RIGHTS - Right resident, right drug, right dose, right route an right time,
are applied for each medication being administered. A triple check of these 5 Rights is recommended at
three steps in the process of preparation of a medication for administration: .
A medication pass observation was made with Staff K, a Registered Nurse (RN), for Resident #38 on
11/30/21 beginning at 9:42 AM. Staff K pulled the following tablets/pills for Resident #38:
One 100 mg (milligram) tablet of Stool Softener.
One 500 mcg (microgram) tablet of Vitamin B12.
One 1000 IU (International Unit)/25 mcg tablet of Vitamin D3.
One 20 mg tablet of Escitalopram (an antidepressant).
One 2 mg tablet of Tolterodine (for overactive bladder symptoms).
One 600/400 mg tablet of Calcium with D3.
During this observation, Staff K also obtained one 20 mg tablet of Citalopram (an antidepressant) and
poured it into the medication cup with the other pills for Resident #38. The surveyor noted the medication
was for a different resident. After the RN pulled all the medications for Resident #38, the surveyor asked to
look at the pill card for the Citalopram again. The RN pulled the card back out of the medication cart, looked
at his eMAR (electronic Medication Administration Record), and looked at the card again and stated the
medication was not due at this time. The RN started to put the card back into the medication cart when the
surveyor asked the RN to look again at the medication card to ensure the five rights of administration. The
RN then noticed the medication that he had obtained for administration to Resident #38, that he thought
was just not due at that time, was actually for another resident.
Before administration of the medication and after disposal of the Citalopram, the RN verified he had six pills
to administer to Resident #38.
Review of the physician orders after the administration of the medications revealed the following:
Cyanocobalamin (Vitamin B12) 1000 mcg to be given once daily.
Vitamin D3 1000 IU/25 mcg, give two tablets daily.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105485
If continuation sheet
Page 8 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105485
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/02/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hamlin Place of Boynton Beach
2180 Hypoluxo Road
Lantana, FL 33462
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Both of these medication orders were written with a start date of 07/02/21.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 11/30/21 at 10:43 AM, Staff K was asked to pull up the eMAR for Resident #38 and
obtain the Vitamin B12 bottle from the medication cart. Staff K immediately noticed the 500 mcg (wrong
dose) on the bottle and agreed the order was for 1000 mcg. The RN stated, last week we had the 1000 mcg
tablets. Upon review of the order for the Vitamin D3, Staff K also agreed the dosage was for two tablets, and
that he administered just one tablet.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105485
If continuation sheet
Page 9 of 9
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
FAQ · About this visit
Common questions about this visit
What happened during the December 2, 2021 survey of HAMLIN PLACE OF BOYNTON BEACH?
This was a inspection survey of HAMLIN PLACE OF BOYNTON BEACH on December 2, 2021. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HAMLIN PLACE OF BOYNTON BEACH on December 2, 2021?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.