Lake Worth Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Lake Worth Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 2, 2023

  Based on interview, observation, and record review the facility failed to provide appropriate supervision to prevent an elopement, which resulted in a missing resident, and failed to notify 911 in a timely manner of the missing resident for 1 of 3 sampled elopement risk residents of 7 elopement risk residents in the facility (Resident #1). The deficient practice allowed Resident #1 to exit the facility undetected on [DATE] at 4:47AM and walk approximately 2 miles with bare feet. Resident #1 was found by the police and was transported by Emergency Services to a local hospital for evaluation. […]

• Actual harm, isolatedF609Jun 13, 2025

  Based on observation, interview, record and policy review; the facility failed to ensure reporting of 2 of 2 incidents involving events with major injuries both affecting 1 of 2 sampled residents (Resident #11) reviewed for accidents. The findings included: The facility's Abuse and Neglect Prohibition policy effective 10/24/22 and revised 8/2023 revealed, The center will report such allegations to the state, as per state/federal regulation. The center will report immediately but no later than 2 hours after forming the suspicion of the events that cause the allegation involve abuse or result in serious bodily injury. […]

• Actual harm, isolatedF610Jun 13, 2025

  Based on observation, interview, record review and policy review; the facility failed to thoroughly identify and investigate the alleged witnessed fall and unwitnessed fall for 1 of 2 sampled residents reviewed for accidents (Resident #11). The findings included: The facility's policy titled Change in Condition effective 1/2023 and updated 9/2023 revealed All completed incident reports must be forwarded to the Director of Nursing and Administrator for review within 24 hours of the event. […]

• No harm, potential for more than minimal, widespreadF812Oct 27, 2022

  Based on observation and interview, the facility failed to serve food in a sanitary manner. The findings included: On 10/24/22 at 9:43AM, during an initial tour of the main kitchen, accompanied by the Food Service Director, the following was observed: (1) The oven was dirty with burnt on grease and food. (2) During an inspection of the walk-in refrigerator, there was a full crate of 8oz (ounces) of fat free milk with a date of 10/19/22. The cartons of milk were observed on the residents' breakfast trays to be served to the resident for breakfast. (3) There were two, 24oz containers of cottage cheese observed. The expiration date for one of the containers was 09/26/22 and the other 10/17/22. (4) A staff nurse was observed in the kitchen. The nurse was not wearing any head covering. […]

• No harm, potential for more than minimal, patternF584Mar 1, 2024

  32078 Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents on 1 of 2 units/floors in the facility (2nd floor secured unit). This affected Residents #67, #24, #85, #51, #79, #57, #58, #68, #40, #31, #59, #32, #91, #28). The findings included: The following observations were made during environmental tours on 02/26/24 and 02/27/24 in the secured unit on the second floor of the facility (photographic evidence obtained): room [ROOM NUMBER]B - overbed light string was off; Resident's daughter stated the string pulls off very easily. The daughter must pull on the short little string to turn the light on or off. […]