Treasure Isle Care Center: Flies Swarm Food, PPE Failures - FL
The inspection revealed widespread infection control failures throughout the 33141 facility, including catheter drainage bags left on floors, emergency exits blocked by laundry bins, and call lights placed out of reach for multiple residents.
In one triple-occupancy room housing residents 6, 7 and 8, inspectors documented "open food items, empty food container swarmed with flies, open milk, rotten mango with flies, open crackers, box on the floor with open cookies, urinals on the floor and dirty bathroom." Photographic evidence captured the conditions on March 3.
Resident 7's bedside table held an unwrapped sandwich, open milk containers, and an empty food container covered with flies when inspectors returned four hours later. The flies remained the next day.
The most serious concerns centered on Resident 9, who requires tracheostomy care and feeding through a gastronomy tube. Inspectors found soiled gauze pads on the resident's bedside table with flies landing on both the dirty bandages and an open packet of clean gauze. The contaminated supplies remained in place for more than 24 hours across multiple inspection visits.
"The soiled gauze pads had flies and open packet with the unused gauze pads were on Resident #9's bedside table," inspectors wrote after their final observation on March 4.
Staff failures extended beyond housekeeping. Two certified nursing assistants provided hygiene care to Resident 10, who requires Enhanced Barrier Precautions due to an indwelling catheter, while wearing only gloves instead of the required gowns and gloves.
When questioned, CNA Staff O acknowledged the violation: "I should wear gloves and gown when giving care for residents on Enhanced Barrier Precaution at all times."
Resident 10's catheter drainage bag was found on the floor during the first day of inspection and remained there the next morning, placed inside a grocery bag but still on the floor.
The facility's Infection Control Preventionist told inspectors that "staff gets confused with what Personal Protective Equipment they should wear when providing direct care for residents on Enhance Barrier Precaution." She blamed residents for some conditions, saying they "are not compliant, are aggressive and will not cooperate."
Multiple emergency exits were blocked during the inspection. Fire Exit Door 3 was obstructed by two wheelchairs and two recliners, while Fire Exit Door 17 was blocked with both soiled and clean linen bins.
Call lights sat out of reach for residents 4, 6, 7, 8, 11 and 12 during repeated observations across both inspection days. Licensed Practical Nurse Staff B explained that some residents remove their call lights and "we have to keep explaining why they need it," but admitted she doesn't document when residents refuse to keep the devices within reach.
Resident 4 spent both inspection days covered with a torn and shredded white blanket. When CNA Staff K was asked about the inadequate bedding, she said "the resident was cold and there were no additional blankets available."
Soiled floors plagued multiple rooms. Room 21 had "brown stains and trash on the floor" that remained unchanged between morning and afternoon observations. Another room's floor showed "red stains" and scattered cup covers.
A urinal containing urine sat visible from the hallway in one room. Two CNAs later acknowledged "it should not have been there because of privacy and infection control."
Flies infested rooms 106, 107, 108 and 109. Maintenance staff confirmed the facility "has a problem with flies" despite weekly pest control visits and multiple "zappers" installed in hallways.
The facility's written infection control policy promises "a safe sanitary, and comfortable environment" and aims to "decrease the risk of infection and communicable diseases development and transmission." The policy specifically requires Enhanced Barrier Precautions for residents with "wounds and/or indwelling medical devices."
Environmental Services Director told inspectors that floors are cleaned daily and "garbage pans emptied as needed," but acknowledged that clean and soiled linen bins "should not be close to each other" and "should not be blocking the exit door."
Licensed Practical Nurse Staff J summarized multiple violations after viewing photographic evidence: "The linen should never be on the floor and the rooms should be cleaned by housekeeping, when the resident food items are done the staff must toss it out and the milk must not be left to get warm because the resident can become sick."
The inspection documented that Resident 9 was readmitted to the facility with acute and chronic respiratory failure, requiring both tracheostomy care and tube feeding. Resident 10's conditions include paraplegia, seizure disorder and bacteriuria, with care plans noting infection risks from the indwelling catheter.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Treasure Isle Care Center from 2025-03-04 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
TREASURE ISLE CARE CENTER in NORTH BAY VILLAGE, FL was cited for violations during a health inspection on March 4, 2025.
The flies remained the next day.
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.