Inspection visit
Inspection
18 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 18 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, policy review, record review and interview the facility failed to identify and develop a plan of
care for 1 of 1 sampled residents reviewed for accidents (Resident #74).
The findings include:
The facility policy titled Wandering and Exit Seeking dated 2015 states the interdisciplinary team evaluates
the patient's history and current clinical condition to identify patients at risk for wandering or exit seeking
and develops a patient specific plan of care. Patients that have been identified as at risk for unsafe
wandering or elopement are included in the Center Watch Process. A picture is taken to identify the patient
and the center completes a profile worksheet with pertinent physical and health information to be placed in
the Center Watch Profile Binder.
Observation on 02/07/2022 at 10:09 AM noted Resident #74 out of bed sitting in a chair with an alert
bracelet on. (The personal security bracelet serves as an alert to the patient of safe boundary limits and as
an alert to staff if patient is close to an alarmed door)
Record review for Resident #74 revealed an admission date of 11/03/2021, with diagnosis including
gastrointestinal hemorrhage (bleeding), chronic kidney disease, diabetes, dementia, psychosis,
encephalopathy (disease that alters brain function) and stroke. The Minimum Data Set, dated [DATE] listed
a Brief Interview of Mental Status of 5, which indicates severe cognitive impairment and under behaviors
documented daily wandering. A physician's order was noted dated 12/30/2021 for an alert bracelet. Record
review lacked evidence of a care plan for identifying the resident at risk for wandering. A Mood/Behavior
Note dated 1/19/2022 at 00:24 stated the Resident was very restless during the shift. She kept getting out
of bed, taking off her clothes.
During an interview on 02/09/2022 at 7:00 AM Staff E stated Resident#74 has an alert bracelet. Staff E
said, they check it every shift. If the resident is agitated or acting up, they take turns watching her. If an
alarm goes off, they go to all the doors to make sure no one is trying to leave. Mostly they just try to keep
her busy.
Upon interview on 02/09/2022 at 3:00 PM, Staff A, stated each unit has a book for exit seekers/wanderers
with their information and picture. She stated that residents at risk for wandering or elopement should have
a care plan addressing it. Staff A verified Resident #74 has a physician's order for an alert bracelet, verified
there was no care plan addressing wandering and Resident #74 was not listed in the units exit seeking
book. A copy of the list of residents from the Exit Seekers Book was provided.
(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 12
Event ID:
105496
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
105496
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Isles of Boynton Nursing and Rehab Center
3001 South Congress Avenue
Boynton Beach, FL 33426
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Upon interview on 02/10/2022 at 10:05 AM when asked how they know if their resident is exit seeking or at
risk for wandering, Staff F stated each unit has a book with their information and pictures in it. She stated if
a resident cannot be found, they do a room search, notify the Supervisor, and call the police.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105496
If continuation sheet
Page 2 of 12
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
105496
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Isles of Boynton Nursing and Rehab Center
3001 South Congress Avenue
Boynton Beach, FL 33426
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to ensure care staff participation in the development of care
plans and participation in the care plan meetings for 6 of 27 sampled residents (Resident #67, 11, 18, 87,
12, and 42) reviewed for care plans; and the facility failed to conduct a care plan conference at least
quarterly with resident and/or representative and IDT (Interdisciplinary Department Team) for 1 of 27
sampled residents (Resident #90) reviewed for care plans.
The findings included:
During an interview, on 02/10/22 at 12:09 PM, with Staff K, CNA (Certified Nursing Assistant), when asked
about participation in care planning and care plan meetings, Staff K replied that she does not attend the
care plan meetings.
During an interview, on 02/10/22 at 12:12 PM, with Staff L, CNA, when asked about participation in care
planning and care plan meetings, Staff L replied that she does not attend the care plan meetings.
During an interview, on 02/10/22 at 12:13 PM, with Staff M, RN (Registered Nurse), when asked about
participation in care planning and care plan meetings, Staff K replied, sometimes, but not for a while. Staff
K further stated that she had not participated in resident care plan meetings within the last year.
During an interview, on 02/10/22 at 12:17 PM, with Staff N, CNA, when asked about participation in care
planning and care plan meetings, Staff N replied that she does not attend the care plan meetings.
During an interview, on 02/10/22 at 2:30 PM, with Staff I, CNA, Staff I stated that she had never attended a
resident care plan meeting.
During an interview, on 02/10/22 at 2:32 PM, with Staff J, CNA, Staff J stated that she had never attended a
resident care plan meeting.
1). Review of a 'Interdisciplinary Care Plan conference record for Resident #87, dated 01/27/22, revealed
documentation of attendance by Activities, Dietary, and Social Services. There was no documentation of
point of care staff, with direct responsibility for the resident, being in attendance or having participated in
the care planning process or meeting.
2). Review of a 'Interdisciplinary Care Plan conference records for Resident #42, dated 09/28/21 revealed
documentation of attendance by Activities, Dietary and Social Services. There was no documentation of
point of care staff, with direct responsibility for the resident, being in attendance or having participated in
the care planning process or meeting.
3). Review of an Interdisciplinary Care Plan conference record for Resident #67, dated 01/25/22, revealed
documentation of attendance by Activities, Dietary and Social Services. There was no documentation of
point of care staff, with direct responsibility for the resident, being in attendance or having participated in
the car planning process or meeting.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105496
If continuation sheet
Page 3 of 12
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
105496
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Isles of Boynton Nursing and Rehab Center
3001 South Congress Avenue
Boynton Beach, FL 33426
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
4). Review of a Interdisciplinary Care Plan conference record for Resident #12, dated 11/18/21, revealed
documentation of attendance by Activities, Dietary and Social Services. There was no documentation of
point of care staff, with direct responsibility for the resident, being in attendance or having participated in
the care planning process or meeting.
5). Review of a Interdisciplinary Care Plan conference record for Resident #11, dated 02/12/22, it was
noted that the Resident care plan conference did not include any direct care staff signatures on the
documentation for the care plan conference.
6). Review of a Interdisciplinary Care Plan conference record for Resident #18, dated 02/12/22 revealed
that the documentation of the care plan conference did not show evidence by signature that direct care staff
was in attendance at the conference.
7). Record review revealed Resident #90 was admitted to the facility on [DATE], with a BIMS (Brief
Interview for Mental Status) score of 13, indicating intact cognition. The Resident diagnosis: Cerebral
infartion unspecified, other dspecified disorder of muscle. Futher record review revealed that the Resident
did not have any docomented evidence in her chart that she had attended a care plan conference since
admission.
During an interview on 02/08/22 at 9:47 AM, the Resident was asked if she had attended care plan
conference and she answered no.
During an interview on 02/09/22 11:26 AM, with the Social Services Director, regarding Resident #90's care
plan conference documentation, she stated that she has been employed at the facility since August of
2021. She confirmed that she did not have any documentation of attendance for Resident# 90's care plan
conference. She also stated that she recieves a schedule with the residents names that are due for a care
plan conference from the MDS (Minimum Data Set) Coordinator. She further explained that it is the
Receptionist's duty to call and invite the families to the care plan conferences, which she conducts.
On 02/09/22 at 11:53 AM, during an interview with the MDS Coordinator, he stated he has been employed
with the facility since 11/19/21. He stated that he schedules the care plan meetings based on projected
time of completion. He further confirmed there was no care plan conference documented for Resident #90,
since admission. The resident's last cobra assessment was completed on 10/15/21 and there was no
record of a care plan conference.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105496
If continuation sheet
Page 4 of 12
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
105496
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Isles of Boynton Nursing and Rehab Center
3001 South Congress Avenue
Boynton Beach, FL 33426
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
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, interview, and record review, the facility failed to obtain consults as ordered for 2 of 2 sampled
residents (Resident #85) for a dermatology consult and (Resident #74) for a nephrology and hematology
consult.
Residents Affected - Few
The findings included:
1. An observation of Resident #85 was conducted on 02/07/22 at 10:30 AM. Resident #85 was observed in
bed, with his legs uncovered. The resident's lower legs, from the knee cap down, were observed to be very
dry, flaky, and with multiple scabs. At the time of observation Resident #85 stated his legs were itchy, and at
one time, they were applying an ointment on them.
Record review revealed Resident #85 was admitted to the facility on [DATE]. A comprehensive assessment
dated [DATE] documented the resident was cognitively intact, and required limited one-person assist with
activities of daily living.
A review of Resident #85's orders revealed an order dated 12/16/21 for a dermatology consult for abnormal
leg rash.
Further review of Resident #85's record did not reveal any evidence of the resident being evaluated by
dermatology, as of 02/10/22, at the time of the survey.
An interview was conducted with Resident #85's nurse on 02/10/22 at 1:20 PM. The nurse stated she was
an agency nurse. She would normally document in the progress notes if a resident was seen by a
consulted physician.
An interview was conducted with Staff Z, Unit Manager for Medbridge Unit, on 02/10/22 at 1:30 PM. Staff Z
stated when a resident goes out for a consult, they go with a packet that contains a blank progress note
and order sheet. Staff Z stated 90% of time they come back with the same packet not filled out. Staff Z
stated she does not know how to tell if a resident went for a consult unless it was documented in progress
notes by the nurse. Staff Z further stated new dermatologist just started coming to the facility. If a resident
did not have any notes or orders, the resident was not on the list to be seen. The resident will probably be
seen next visit. Staff Z did not know when that would be.
2) Record review for Resident#74 revealed documented an admission date to the facility on [DATE], with
diagnosis including gastrointestinal hemorrhage (bleeding), chronic kidney disease, diabetes, dementia,
and stroke. On 12/09/2021 a physician order was documented for a Hematology consult (physician who
specializes in diseases of the blood). On 12/10/2021 a physician order was documented for a Nephrology
consult (physician who specializes in diseases of the kidney). Further record review lacked documentation
of consults being processed or completed.
During an interview, the Director of Nurses (DON) stated on 02/10/2022 at 12 noon, the scheduler used to
make the appointments, but he resigned. Since then, any new orders are printed each day and reviewed.
She stated that both physician consultation orders for Resident#74 were missed. In addition, she said she
does not believe there is a policy regarding processing orders for consultations and would provide it if
found. No policy was provided.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105496
If continuation sheet
Page 5 of 12
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
105496
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Isles of Boynton Nursing and Rehab Center
3001 South Congress Avenue
Boynton Beach, FL 33426
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
FORM CMS-2567 (02/99)
Previous Versions Obsolete
On 02/10/2022 at 12:15 PM, Staff G stated she was working on getting the Hematology and Nephrology
consultations for Resident #74.
On 02/10/2022 at 12:49 PM, Staff H, Regional Director stated that the Nephrology consult was coded
completed by error when it was not done. She went on to state that the process for consults is being looked
at.
Event ID:
Facility ID:
105496
If continuation sheet
Page 6 of 12
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
105496
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Isles of Boynton Nursing and Rehab Center
3001 South Congress Avenue
Boynton Beach, FL 33426
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 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to provide care and services to prevent
significant weight loss for 1 of 4 sampled residents reviewed for nutrition, (Resident #87).
Residents Affected - Few
The findings included:
The facility's policy titled Weight Management Guidelines, documented in the section for 'Guidelines', Newly
admitted patients are weighed upon admission and then weekly for a total of four (4) consecutive weeks,
then monthly. readmitted patients may or may not need weekly weights and this may be determined by the
interdisciplinary team.
Record review revealed Resident #87 was admitted to the facility on [DATE]. According to the resident's
most recent, an admission Minimum Data Set (MDS) assessment indicated that Resident #87 had a Brief
Interview for Mental Status (BIMS) score of 12, indicating 'moderately intact'. The assessment documented
that the resident required 'Extensive assistance' and 'One person physical assist' for eating and that the
resident was dependent on staff for all Activities of Daily Living (ADLs).
Resident #87's care plan, created on 01/11/22, documented, Risk for altered nutrition r/t (related to) DM
(Diabetes Mellitus), dysphagia, dependence on enteral feeding, cognition deficit, CVA, Risk for
hyperglycemia r/t steroids, Potential for weight changes r/t edema/steroid use.
The goal of the care plan was documented as, will tolerate diet and texture/consistency. Will also tolerate
enteral feeding and flushes with a target date of 04/30/22.
Interventions to the care plan were documented as:
* Administer vitamin/mineral supplements as ordered
* Encourage and assist as needed to consume foods and/or supplements and fluids offered
* Honor advanced directives related to nutritional/hydration support
* Provide diet, enteral feeding and flushes per order
* Report signs or symptoms of diet, texture or enteral feeding intolerance
* Review weights and notify physician and responsible party or significant weight change
Resident #87's orders included:
CHO (Controlled), No Added Salt diet, Pureed texture - 01/07/22
Enteral Feed - one time a day Verify placement. Flush with 30mL of water. Start Glucerna 1.5 at 1700 and
continue until 1200 mLs have infused. AND one time a day Glucerna 1.5 , infuse at 60 mLs/hour. Flush with
40 mLs water,every hour during pump infusion. 01/08/22 and discontinued on 02/08/22
Resident #87's order prior to 02/08/22 for Enteral Feed was as follows: one time a day Verify
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105496
If continuation sheet
Page 7 of 12
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
105496
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Isles of Boynton Nursing and Rehab Center
3001 South Congress Avenue
Boynton Beach, FL 33426
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 0692
Level of Harm - Minimal harm
or potential for actual harm
placement. Flush with 30mL of water. Start Glucerna 1.5 at 1700 and continue until 1200 mLs have infused.
AND one time a day Glucerna 1.5 , infuse at 60 mLs/hour. Flush with 40 mLs water,every hour during pump
infusion. - 02/07/22
Record reiew revealed upon admission on [DATE], the resident weighed 250 lbs.
Residents Affected - Few
During an interview, on 02/09/22 at 12:48 PM, with Staff K, CNA, when about Resident #87's ability to
communicate, Staff K replied, She is able to communicate and participate in her care. I fed her, she took a
little, not too much. She said 'I don't want it. She just took the juice. Staff K confirmed that Resident #87 was
compliant with care and had not refused to be weighed at any time.
On 02/10/22 at 10:40 AM, at the request of this surveyor, Resident #87 was weighed using a hoyer lift. The
result was that the resident weighed 221 pounds, which is 11.60 % loss since previous weight on
admission to the facility.
During an interview with the Registered Dietitian, on 02/09/22 at 10:15 AM, when asked regarding
documentation of a resident refusing to be weighed, the Registered Dietitian stated that it would have been
documented in the residents' progress notes. The Registered Dietitian confirmed that there was no
documentation of Resident #87 refusing to be weighed and no weights documented since admission
weight.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105496
If continuation sheet
Page 8 of 12
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
105496
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Isles of Boynton Nursing and Rehab Center
3001 South Congress Avenue
Boynton Beach, FL 33426
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 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to provide nutritional supplement via enteral
method as ordered, for 1 of 2 sampled residents reviewed for Tube Feeding, Resident #42.
The findings included:
In the facility's policy titled 'Tube Feedings: Feedings' under the heading of 'Procedure', the policy
documented, 1. Verify medial practitioner's order including prescribed enteral formula; administration
method, volume and rate; and type, volume, and frequency of water flushes.
Record review revealed Resident #42 was admitted to the facility on [DATE]. According to the resident's
most recent complete assessment, a Quarterly Minimum Data Set (MDS) dated [DATE], Resident #42 was
not assessed for cognition due to 'resident is rarely/never understood'. The MDS documented that the
resident was dependent on staff for all Activities of Daily Living (ADL). Resident #42's diagnoses at the time
of the assessment included: Anemia; coronary artery disease; Orthostatic hypotension; Diabetes Mellitus;
Hyponatremia; Hyperlipidemia; Aphasia; Non-Alzheimer's Dementia; Seizure disorder; Dysphagia,
Oropharyngeal phase; Paroxysmal Atrial fibrillation; erythematous conditions; Vitamin D deficiency;
Hypokalemia; Aphasia; GERD. Further review of Resident #42's electronic health record and paper-based
health record showed that Resident #42 was not insulin dependent.
Resident #42's orders included:
Enteral Feed - one time a day Start Glucerna 1.5 at 1300 and continue until 1100_mLs have infused. AND
one time a day Glucerna 1.5 Formula, infuse at 55_mLs/hour. Flush with_45 mLs /hr during pump infusion.
07/08/21
Resident #42's care plan, created on 07/27/21, documented, Need for feeding tube/ potential for
complications of feeding tube use related to swallowing impairment.
The goal of the care plan was documented as, Will have no complications related to tube feeding or
presence of tube
Interventions to the care plan included:
* Administer tube feeding formula, hydration and flushes per order
* Check tube placement and residuals per guideline or physician order
* Elevate head 30-45 degrees
* Nothing by mouth
* Obtain Labs s ordered and report results to physician
* Provide care of ostomy site per orders
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105496
If continuation sheet
Page 9 of 12
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
105496
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Isles of Boynton Nursing and Rehab Center
3001 South Congress Avenue
Boynton Beach, FL 33426
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 0693
* Provide oral hygiene daily and prn
Level of Harm - Minimal harm
or potential for actual harm
* Report signs of aspiration or intolerance of feeding
Residents Affected - Few
* Report signs/symptoms of infection at ostomy site such as redness, tenderness, heat, drainage, fever,
acute mental changes, functional decline in ADLs.
Resident #42's care plan, created 06/08/21 and most recently revised on 09/16/21, documented, Risk for
altered nutrition r/t dependence on PEG tube, CVA, hemiparesis, +/-diuretic use, potential for weight
fluctuations, potential for hyper/hypoglycemia r/t DM/oral meds and insulin and fragile skin.
The goal of the care plan was documented as, Will tolerate enteral feeding and flushes with a target date of
02/17/22.
Interventions to the care plan included:
* Abdominal binder In place to protect peg placement
* Administer vitamin/mineral supplements as ordered
* Monitor labs, skin tf/flushes and hydration status prn
* Provide enteral feeding and flushes as ordered
* Report signs and symptoms of hyperosmolar reaction such as nausea, vomiting, hyperglycemia
* Report signs or symptoms feeding intolerance
* Review weights and notify physician and responsible party of significant weight change
Resident #42's weights were documented as:
On 02/07/22, Resident #42 weighed 143 pounds
On 11/10/21, Resident #42 weighed 146 pounds
On 09/01/21, Resident #42 weighed 146 pounds
There were no other weights documented in the resident's record and it was not possible to determine
significant weight loss/gain due to the resident not having weights monitored per facility protocols.
On 02/07/22 at 12:36 PM, Resident #42 was observed in bed with Tube Feeding Jevity 1.5 Cal initiated at
55 ml/hr. The date marked on container documented that it was initiated on 02/06/22. According to Resident
#42's Medication Administration Record (MAR) revealed that the container of supplement was initially
started/initiated on 02/06/22 at 1:30 PM. At the time of the observation, there was approximately 400 ml
remaining in the 1000 ml container. At a rate of 55 ml/hr over 23 hours, Resident #42 should have received
1265 ml of supplement. A review of the resident's electronic health record and paper-based health record
showed no documentation to justify the supplement not being
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105496
If continuation sheet
Page 10 of 12
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
105496
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Isles of Boynton Nursing and Rehab Center
3001 South Congress Avenue
Boynton Beach, FL 33426
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 0693
given/dispensed as ordered and not receiving the ordered supplement.
Level of Harm - Minimal harm
or potential for actual harm
On 02/08/22 at 7:40 AM, Resident #42 was observed in bed with head of bed elevated and with
supplement being dispensed at 55 ml/hr. Date mark on the container documented that the supplement was
initiated on 02/07/22 at 16:00 (4:00 PM). At the time of the observation, there was approximately 500 ml
remaining in the 1000 ml container (approximately 500 ml dispensed to Resident #42). At a rate of 55 ml/hr
for 15.5 hours, the resident should have had dispensed 852 ml. Review of resident's electronic health
record and paper-based health record, showed no documentation to justify the supplement not being
given/dispensed as ordered.
Residents Affected - Few
On 02/09/22 at 8:16 AM, Resident #42 was observed in bed with the head of bed elevated and tube
feeding initiated at 55 ml/hr. At the time of the observation there was less than 200 ml remaining of the
1000 ml container that was initiated on 02/08/22 at 12:05 PM, according to the date-mark on the container.
At a rate of 55 ml/hr over 20 hours, the resident should have had dispensed 1100 ml of the supplement.
Review of the resident's electronic health record and paper-based health record showed no documentation
to justify the supplement not being given/dispensed as ordered.
During an observation of a second floor storage room, on 02/09/22 at 10:31 AM, accompanied by the
Central Supply Clerk, an unopened case of Glucerna 1.5, containing 6 - 1000 ml containers of the
supplement was located on a shelf in the storage room. When the Central Supply Clerk was asked when
the case of supplement was received, the Central Supply Clerk replied, Monday last week (01/31/22).
During an interview with the Registered Dietitian and the Regional Dietitian, on 02/09/22 at 10:15 AM, the
Registered Dietitian acknowledged understanding of the concerns and confirmed that Resident #42 was
not receiving the supplement as ordered.
During the interview, the Registered Dietitian and the Regional Dietitian were unable to find any
documentation to justify the resident not receiving enteral feeding as ordered.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105496
If continuation sheet
Page 11 of 12
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
105496
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/10/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Isles of Boynton Nursing and Rehab Center
3001 South Congress Avenue
Boynton Beach, FL 33426
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observation, policy review, record review and interview, the facility failed to ensure proper storage
of medications for 1 of 8 sampled residents (Resident #21).
Residents Affected - Few
The findings include:
Facility policy titled Medication Administration: Medication Pass, dated 03/2010 states, remain with patient
until administration of medication complete.
On 02/07/2022 at 10:50 AM during an interview with Resident #21 a medicine cup was observed on his
bedside stand containing 7 pills.
Record review for Resident #21 revealed an admission date of 11/28/2021 with diagnosis including heart
disease, dementia, depression, and diabetes. The record lacked any documentation for a physician's order
or care plan to self-administer medication.
On 02/07/2022 at 11:35 AM, Staff A was informed of what appeared to be pills in a medicine cup that were
observed on Resident #21's bedside stand. She stated that is not correct procedure, removed the pills from
the room and notified the Director of Nurses (DON). Staff A then went to Staff B with the medications. Staff
B stated he watched Resident #21 take his medications this morning. After examination of the pills and
medication record review by Staff A and Staff B, it was stated that the pills were thought to be last night's
medications.
On 02/08/22, the surveyor received documentation from the DON dated 02/07/22 stating medications were
found at the bedside for Resident#21, the resident's physician and family were notified and that an
investigation was done followed by staff medication pass education.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105496
If continuation sheet
Page 12 of 12
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Back to topCitations
18 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.
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0018GeneralS&S Fpotential for harm
Establish procedures for tracking staff and patients during an emergency.
- 0020GeneralS&S Fpotential for harm
Establish policies and procedures including evacuation.
- 0022GeneralS&S Fpotential for harm
Establish policies and procedures for sheltering.
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0293GeneralS&S Dpotential for harm
Have properly located and lighted "Exit" signs.
- 0346GeneralS&S Fpotential for harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- 0351GeneralS&S Dpotential for harm
Install an approved automatic sprinkler system.
- 0352GeneralS&S Fpotential for harm
Properly install and monitor supervisory attachments on automatic sprinkler systems.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0929GeneralS&S Epotential for harm
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
FAQ · About this visit
Common questions about this visit
What happened during the February 10, 2022 survey of ISLES OF BOYNTON NURSING AND REHAB CENTER?
This was a inspection survey of ISLES OF BOYNTON NURSING AND REHAB CENTER on February 10, 2022. The surveyor cited 18 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ISLES OF BOYNTON NURSING AND REHAB CENTER on February 10, 2022?
Yes, 18 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Conduct risk assessment and an All-Hazards approach."
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.