Legacy at Boca Raton Rehabilitation and Nursing Ce

In the surveyor’s words

From the most serious findings on record at Legacy at Boca Raton Rehabilitation and Nursing Ce, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 12, 2021

  Based on observation, interview, and record review, the facility failed to prevent neglect by not supervising and providing a safe environment for a resident with an elopement risk for 1 of 4 sampled residents (Resident #1). Resident #1 was a vulnerable resident who exited the facility unsupervised on 03/20/21 and was found almost a mile away in a residential area at 8:30 PM. The facility did not know she was missing. She was returned safely to the facility by her family. After that incident, the facility failed to ensure the resident received the necessary care and services to prevent her from exiting the facility again unsupervised on 03/22/21 and 03/23/21. The facility's failure to prevent Resident #1 from exiting placed this resident at a likelihood of serious harm, injury and death. […]

• Immediate jeopardy, isolatedF689Apr 12, 2021

  Based on observation, interview, and record review, the facility failed to provide supervision and a safe environment to prevent elopement for 1 of 4 sampled residents (Resident #1). Resident #1 was a vulnerable resident who exited the facility unsupervised on 03/20/21 and was found almost a mile away in a residential area at 8:30 PM. The facility did not know she was missing. She was returned safely to the facility by her family. After that incident, the resident exited the facility again unsupervised on 03/22/21 and 03/23/21. The facility's failure to prevent Resident #1 from exiting placed this resident at a likelihood of serious harm, injury and death. While out of the facility on 03/20/21, Resident #1 got lost. […]

• No harm, potential for more than minimal, widespreadF812Apr 10, 2024

  Based on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The findings included: During the initial Food Service Observation Sanitation Tour conducted on [DATE] ay 8:40 AM, and subsequent tours conducted on [DATE] at 7 AM and 11:30 AM with the Foods Service Director, and [DATE] at 11:30 AM, accompanied with the Corporate Dietary Manager, the following were noted: 1) [DATE] (8:40 AM Tour): * Large uncovered cart full of uncovered soiled resident food trays located at the entrance to the dietary department. […]

• No harm, potential for more than minimal, widespreadF812Feb 2, 2023

  Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards that include: failure to maintain refrigeration units, failure to ensure washing in the 3-compartment sink, failure to maintain and clean ceiling and light fixtures, and failure to clean and sanitize commercial food preparation equipment. The findings included: 1) During the initial kitchen/food service sanitation tour conducted on 01/30/23 at 9 AM, accompanied with the Food Service Supervisor (FSS), the following were noted: (a) Observation of the walk-in freezer noted that thermometer gauge to be 40 degrees F and also noted that the entry/exit door was ajar and would not close tightly and noted a heavy,… […]

• No harm, potential for more than minimal, patternF584Apr 10, 2024

  Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior on the B Wing (1 of 33 rooms), C Wing (17 of 33 rooms) and D Wing (1 of 39 rooms). The findings included: During the initial resident/room screenings conducted on 04/07/24 from 9 AM-3 PM, and the Environment Tour conducted on 04/10/24 at 10 AM, accompanied with the facility's Assistant Administrator and Corporate Housekeeping Manager, the following were noted: B Wing: room [ROOM NUMBER] - Electric bed (A Bed) not working, staff not able position resident for assistance with feeding the lunch meal. […]