Inspection Reports for
Chatsworth at Pga National
347 HIATT DR, PALM BCH GDNS, FL, 33418-7106
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Inspection Report — Oct 7, 2025
Annual Inspection
Date: Oct 7, 2025
Visit Reason
The report covers 19 inspections of Chatsworth at Pga National from August 23, 2012 to October 7, 2025, including follow-up visits confirming corrections.
Findings
Across the inspection history, 17 Class 3 deficiencies were recorded with no serious deficiencies. The most recent visit recorded no deficiencies.
Citations (17)
Medication - Storage and Disposal — cited April 9, 2024, corrected August 13, 2024
ECC - Training — cited April 9, 2024, corrected August 13, 2024
Resident Care - Elopement Standards — cited May 7, 2019, corrected July 10, 2019
Staffing Standards - Staff — cited May 7, 2019, corrected July 10, 2019
Training - Assis Self-admin Meds & Med Mgmt — cited May 7, 2019, corrected July 10, 2019
Resident Care - Rights & Facility Procedures — cited April 21, 2017, corrected May 24, 2017
Medication - Storage and Disposal — cited April 21, 2017, corrected May 24, 2017
Staffing Standards - Staff — cited April 21, 2017, corrected May 24, 2017
Training - Staff In-service — cited April 21, 2017, corrected May 24, 2017
Training - Do Not Resuscitate Orders — cited April 21, 2017, corrected May 24, 2017
Food Service - Dietary Standards — cited April 21, 2017, corrected May 24, 2017
Medication - Records — cited April 2, 2015, corrected May 20, 2015
Medication - Storage and Disposal — cited April 2, 2015, corrected May 20, 2015
Training - Staff In-service — cited May 6, 2013, corrected July 12, 2013
Training - Do Not Resuscitate Orders — cited May 6, 2013, corrected July 12, 2013
ECC - Service Plans — cited May 6, 2013, corrected July 12, 2013
ECC - Services — cited May 6, 2013, corrected July 12, 2013
Report Facts
Inspections: 19
Visits with deficiencies: 5
Clean visits: 9
Deficiencies: 17
Serious deficiencies: 0
Legal actions: 1
Total fines: 500
Inspection Report — Apr 17, 2025
Date: Apr 17, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with nutritional care standards, specifically regarding the maintenance of acceptable nutritional status and timely nutritional interventions for residents.
Findings
The facility failed to maintain acceptable nutritional parameters and did not provide timely nutritional interventions for Resident #23, who experienced significant weight loss. The dietitian missed reviewing the full weight history and did not order appropriate interventions despite the resident's significant weight loss and underweight status.
Citations (1)
F 0692: The facility failed to provide enough food and fluids to maintain Resident #23's health, resulting in a 10.3 percent weight loss over six months without timely nutritional interventions.
Report Facts
Weight loss percentage: 10.3
Weight loss in pounds: 13.9
Weight measurements: 134.9
Weight measurements: 127
Weight measurements: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Interviewed regarding weight monitoring and reporting procedures. |
| General Manager for Dining | Interviewed about food preferences and meal ticket documentation. | |
| Clinical Dietitian | Interviewed about nutritional assessments, weight loss monitoring, and interventions. | |
| Assisting Director of Nursing (ADON) | Interviewed about care plan updates and high-risk rounds. | |
| Director of Nursing (DON) | Interviewed about care plan updates and acknowledged findings. |
Inspection Report — Jan 19, 2024
Routine
Date: Jan 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights and care, including honoring resident preferences and providing appropriate catheter care to prevent urinary tract infections.
Findings
The facility failed to honor the preferred name of one resident, Resident #10, despite documentation and family requests. Additionally, the facility failed to provide appropriate care for residents with indwelling urinary catheters, including improper catheter tubing positioning and lack of education on catheter risks for three residents.
Citations (2)
F 0561: The facility failed to honor Resident #10's preferred name as documented and requested by the resident's representative, with multiple staff using the resident's legal name instead.
F 0690: The facility failed to ensure proper care and securing of indwelling urinary catheters for Residents #24 and #45, and failed to educate Resident #38 on the risks of prolonged catheter use and follow-up with urology.
Report Facts
Residents affected: 1
Residents affected: 3
BIMS score: 1
BIMS score: 15
Date of catheter order: 2023
Date of urology consult order: 2023
Date of urology appointment: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant (CNA) | Named in preferred name and catheter care findings |
| Staff C | Certified Nursing Assistant (CNA) | Named in preferred name and catheter care findings |
| Staff D | Certified Occupational Therapy Assistant (COTA) | Named in preferred name findings |
| Staff E | Activity Assistant | Named in preferred name findings |
| Staff F | Registered Nurse (RN) | Named in preferred name and catheter care findings |
| Staff G | Physical Therapy Assistant (PTA) | Named in preferred name findings |
| Director of Nursing | Director of Nursing (DON) | Named in preferred name and catheter care findings |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Named in catheter care findings |
| Scheduler | Licensed Practical Nurse (LPN) | Named in catheter care findings related to urology appointments |
| Infection Preventionist | Infection Preventionist (IP) | Named in catheter care findings |
| Clinical Manager | Clinical Manager | Named in catheter care findings |
Inspection Report — Sep 8, 2022
Date: Sep 8, 2022
Visit Reason
The inspection was conducted to review the facility's compliance with documentation standards related to resident medical records and medication orders, focusing on the accuracy of diagnoses linked to medications and discharge documentation.
Findings
The facility failed to ensure accurate documentation for 4 of 22 sampled residents. Multiple medication orders for Residents #18, #20, and #36 documented incorrect diagnoses, and Resident #51's discharge location was incorrectly documented in the Minimum Data Set Discharge Report.
Citations (2)
F 0842: The facility failed to safeguard resident-identifiable information and maintain accurate medical records. Medication physician orders for Residents #18, #20, and #36 documented improper or mismatched diagnoses for multiple medications.
F 0842: Resident #51's Minimum Data Set Discharge Report documented an incorrect discharge location, listing hospital instead of hospice, triggering a review for hospitalization during the survey process.
Report Facts
Residents sampled: 22
Residents with documentation errors: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Interviewed regarding diagnosis listing for medications on physician's orders |
| Director of Nursing | Director of Nursing (DON) | Interviewed about use of diagnoses in electronic medication ordering and documentation errors |
| MDS Coordinator | MDS Coordinator | Interviewed about admission diagnosis assignment and medication order review process |
| Risk Manager/Staff Developer | Risk Manager/Staff Developer | Interviewed about use of electronic medical record system and diagnosis entry process |
3 CMS Surveys
CMS Survey — Sep 8, 2022
Sep 8, 2022
CMS Survey — Jan 19, 2024
Jan 19, 2024
CMS Survey — Apr 17, 2025
Apr 17, 2025
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