Medicana Nursing: Drug-Resistant Infection Ignored - FL
Federal inspectors cited Medicana Nursing and Rehab Center for infection control failures during a January 16 survey, finding the facility ignored its own safety protocols and left residents vulnerable to spreading infections.
The violations centered on two residents with serious medical conditions requiring enhanced barrier precautions.
Resident 60 had been placed on enhanced barrier precautions in early December for ESBL, a multi-drug resistant organism found in urine. Those precautions ended December 11. Three days later, doctors ordered another urine culture.
The results came back December 18 showing VRE — Vancomycin Resistant Enterococcus, another dangerous drug-resistant organism. Doctors prescribed Zyvox, a powerful antibiotic, for seven days starting December 19.
But inspectors found no evidence the facility placed the resident back on precautions or conducted any follow-up after the antibiotic treatment ended. The resident had moderate cognitive impairment and depended on staff for daily care activities.
The second case involved a diabetic resident with chronic wounds who was admitted in September. Doctors ordered enhanced barrier precautions every 24 hours for wound care, along with specialized therapy three times weekly using a Vaporox ultrasound machine.
On January 15 at 12:42 PM, inspectors observed the resident receiving wound therapy on a large heel wound with drainage. Six minutes later, Staff K, a physical therapist, arrived to attend to the Vaporox machine.
The therapist removed the protective bag covering the resident's foot, raised the leg, and handled the wounded area directly. Throughout the procedure, Staff K wore no gown despite the facility's enhanced barrier precautions requiring protective equipment during direct patient contact.
Facility policy mandates gowns and gloves during close contact activities including bathing, dressing, wound care, and transferring patients with multi-drug resistant organisms or indwelling medical devices.
When inspectors called Staff K the next day, the therapist acknowledged awareness of the enhanced barrier precaution procedures and admitted to not wearing the required gown during patient care.
The infection control failures extended to the facility's antibiotic stewardship program, which inspectors found ineffective for both residents.
The program requires a multidisciplinary committee including the medical director, director of nursing, and consultant pharmacist to monitor appropriate antibiotic use. The medical director should set prescribing standards, nursing should establish monitoring protocols, and the pharmacist should review orders during medication reviews.
For Resident 60, the stewardship program documented that antibiotic orders didn't meet McGeer criteria — clinical standards used to determine when infections require treatment. Despite this finding, outside practitioners continued prescribing antibiotics without facility oversight.
An antibiotic stewardship note from December 5 stated "McGeer not met" for the first antibiotic course, leading to a reduction from nine days to seven days. Another note from December 16 again documented "McGeer not met" for a second antibiotic prescribed for elevated white blood cell count.
The nurse practitioner who ordered Resident 60's antibiotics told inspectors she doesn't use McGeer criteria to determine antibiotic necessity, calling it "a guideline only." She said she doesn't attend facility meetings or communicate with attending physicians.
The facility's infection control preventionist confirmed the McGeer criteria should guide antibiotic decisions but said the ordering nurse practitioner works for managed care, not facility staff. The preventionist admitted not informing attending physicians about antibiotic orders from outside practitioners.
Resident 60's attending physician told inspectors he was unaware the patient had tested positive for ESBL and VRE infections or received antibiotic treatment. He said he would investigate.
Similar communication breakdowns affected Resident 62, who received a one-time antibiotic injection for elevated white blood cell count. The stewardship program again noted "McGeer not met," but the attending physician told inspectors he was unaware of the antibiotic administration.
The inspection revealed a facility where infection control protocols existed on paper but broke down in practice. Enhanced barrier precautions went unenforced, drug-resistant infections went unmonitored, and communication between prescribers and facility staff was nonexistent.
Resident 71, the diabetic patient with chronic wounds, was rarely or never able to communicate according to assessment records. The resident depended entirely on staff to follow safety protocols during the multiple weekly wound treatments.
The Vaporox therapy required removing protective coverings and direct contact with infected tissue. Without proper protective equipment, staff could spread infections between residents or carry organisms throughout the facility.
VRE infections pose particular dangers in nursing homes, where residents have compromised immune systems and share common spaces. The organism resists vancomycin, one of the strongest antibiotics available, making infections difficult to treat and potentially fatal.
The facility's antibiotic stewardship committee was supposed to prevent inappropriate prescribing and ensure proper monitoring. Instead, outside practitioners prescribed antibiotics that didn't meet clinical criteria while facility physicians remained uninformed about their patients' treatments.
During the inspection, administrators acknowledged the deficiencies when presented with evidence. The administrator confirmed the facility lacked effective corrective action plans for previous infection control violations found during a September 2023 survey.
The January 16 inspection found the same problems persisting more than a year later, with staff still failing to follow basic infection control procedures and administrators unable to coordinate care between different medical providers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medicana Nursing and Rehab Center from 2025-01-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
MEDICANA NURSING AND REHAB CENTER in LAKE WORTH, FL was cited for violations during a health inspection on January 16, 2025.
The violations centered on two residents with serious medical conditions requiring enhanced barrier precautions.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.