Treasure Isle Care Center: Oxygen Device Violation - FL
The violation was documented during a federal health inspection completed March 4, 2025, at the facility located at 1735 N Treasure Drive. Centers for Medicare and Medicaid Services inspectors classified the deficiency as causing minimal harm or the potential for actual harm, and noted that a few residents were affected.
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See the Derila PillowThe citation is short. The underlying concern is not.
Supplemental oxygen is prescribed at a specific liter flow for a reason. Too little and a resident's blood oxygen can drop, starving organs of what they need. Too much and the body's respiratory drive, particularly in patients with chronic lung disease, can be disrupted in ways that are dangerous and fast-moving. The correct number on the flow meter is not a preference. It is part of the treatment.
Treasure Isle Care Center is a nursing facility sitting on North Bay Village's main island, a small municipality wedged between Miami and Miami Beach. The residents who live there are, by definition, people who need a level of care they cannot provide for themselves. For those on supplemental oxygen, that dependence is immediate and physiological.
The inspection report does not name the residents who were affected, does not describe how long the wrong liter flow was in use, and does not say whether anyone experienced symptoms as a result. What it records is that inspectors found the problem, that more than one resident was involved, and that the facility's own staff had not caught it.
That last part is worth sitting with. Oxygen flow rates are not hidden information. The prescribed rate is typically posted at the bedside or written in the care plan. A nurse or aide checking on a resident, or a charge nurse doing rounds, would have access to what the flow meter should read. The inspectors found a gap between what was ordered and what was happening. The facility had not.
CMS rated the harm level at the lower end of its scale, meaning inspectors did not find evidence that residents had suffered significant injury by the time the survey team arrived. That rating reflects what was documented, not necessarily what could have happened over time or what a resident experienced before the inspection date.
The facility's plan of correction was not included in the inspection materials reviewed for this report. For information on how Treasure Isle Care Center responded to the citation, CMS directs the public to contact the nursing home or the Florida state survey agency directly.
Treasure Isle Care Center carries the provider identification number 105408 in the CMS system. The March 2025 survey was a standard health inspection.
Florida has one of the largest nursing home populations in the country, and supplemental oxygen is among the most commonly used medical interventions in long-term care. The state's heat and humidity place additional strain on residents with respiratory conditions, and facilities along the coast, including those in Miami-Dade County, serve populations that skew older and sicker than the national average.
A single deficiency at the lower end of the harm scale does not make Treasure Isle Care Center an outlier. What it does is document a specific moment when the gap between a physician's order and what a resident actually received was wide enough for a federal inspector to see it and write it down.
For the residents on oxygen in that facility, the liter flow on their device was not an abstraction. It was the rate at which they were breathing.
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 violation was documented during a federal health inspection completed March 4, 2025, at the facility located at 1735 N Treasure Drive.
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.