Treasure Isle Care Center: Infection Control Failures - FL
The problems were not subtle, and the staff who spoke with inspectors largely knew it.
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See the Derila PillowTwo certified nursing assistants, identified in the inspection report as Staff L and Staff P, acknowledged during an 8:11 a.m. interview that the urinal on the floor the previous day should not have been there. The reasons were basic: privacy and infection control.
A licensed practical nurse, Staff J, was shown photographs of what inspectors had found. Her response was direct. "The linen should never be on the floor," she told inspectors, "and the rooms should be cleaned by housekeeping." She added that when residents finish food items, staff are supposed to throw them out, and that milk left to sit at room temperature could make a resident sick. She acknowledged the clutter problem, too. "We try to encourage the residents to keep the rooms clutter free but they go out and bring more and that is a safety problem and infection control problem."
The Environmental Services Director, interviewed at 9:57 a.m., said floors are cleaned daily and as needed.
None of that squared with what inspectors documented.
When the facility's Infection Control Preventionist was brought in at 9:22 a.m. and told what inspectors had found, her response shifted the focus away from staff and toward residents. She said staff get confused about which personal protective equipment to wear when providing direct care for residents on Enhanced Barrier Precautions, a protocol that requires gowns and gloves during high-contact activities with residents who have wounds or indwelling medical devices, even when no infection has been confirmed. But when inspectors pressed her on the specific concerns found in individual residents' rooms, she was, according to the report, "adamant that the residents are not compliant, are aggressive and will not cooperate."
The administrator joined that meeting and was told the infection control failures were serious enough to increase the risk of pests and disease.
Enhanced Barrier Precautions exist precisely because the risk of spreading infection does not require a confirmed diagnosis. A resident with a wound or a catheter is already vulnerable. Gowns and gloves during hands-on care are the line between that vulnerability and something worse. The Infection Control Preventionist's own admission, that staff are confused about when to wear that equipment, described a gap at exactly that line.
The facility's infection control policy, in place since October 2021, sets out goals that include providing a safe, sanitary, and comfortable environment and decreasing the risk of infection and communicable disease transmission. Its Enhanced Barrier Precautions policy, updated in April 2024, specifically identifies wounds and indwelling medical devices as triggers for gown and glove use.
The inspection found that neither policy was being reliably followed.
CMS rated the level of harm as minimal harm or potential for actual harm. Some residents were affected.
What the inspection captured was a facility where the people responsible for carrying out infection control could describe the rules clearly when asked and could not reliably execute them when no one was watching. Staff L and Staff P knew the urinal shouldn't be on the floor. Staff J knew the linen shouldn't be there either, knew the milk shouldn't be left out, knew the clutter was a problem. The Infection Control Preventionist knew staff were confused about protective equipment.
The knowing and the doing were not the same thing. And in a building full of people with wounds and medical devices and compromised immune systems, that distance between knowing and doing is where infections begin.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 13, 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 problems were not subtle, and the staff who spoke with inspectors largely knew it.
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.