Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alexander "sandy" Nininger State Veterans Nursing during CMS and state inspections, most recent first.
A resident with a history of adrenalectomy, bipolar disorder, dementia, and hypertension experienced significant weight loss, which the facility failed to address in a timely manner. The dietitian did not attend risk meetings consistently or communicate the weight loss to the resident's practitioner or nursing staff. Despite monitoring the resident's weight, the facility did not implement effective nutritional interventions, leading to a deficiency in maintaining the resident's nutritional health.
The facility did not provide fresh fruit to residents as per the menu, affecting eight residents who reported receiving fresh fruit only once or twice a week instead of daily. The diet technician confirmed the availability of bananas and other fruits but could not explain the discrepancy. Residents involved had various medical conditions and were mostly cognitively intact.
The facility failed to provide palatable and appetizing meals to several residents, as evidenced by consistent complaints about the food's taste and appearance. Despite varying cognitive impairments, residents reported that meals were bland, unappetizing, and inconsistent with their requests. A test tray confirmed the lack of seasoning and color variation, while the Food Service Director attributed the blandness to dietary restrictions, though the issue persisted across different diets.
The facility failed to provide the correct pureed diet consistency for several residents, serving meals that were lumpy and contained solid particles. This inconsistency was observed during multiple meal services, affecting residents with conditions like dysphagia and Parkinson's. The Food Service Director acknowledged the issue, and the Speech Language Pathologist confirmed that the pureed food should be smooth, as per facility policy.
The facility failed to maintain food safety and sanitation standards, affecting 106 residents. Observations revealed improper food storage, unclean kitchen equipment, and unsafe food temperatures. Nourishment rooms also had unsanitary conditions, with unclear cleaning responsibilities among staff.
A resident with Quadriplegia expressed a desire to be out of bed by 10:00 AM, as per their care plan, but was consistently left in bed until after 12:00 PM. Despite communicating this preference to staff, the resident was told the schedule was based on staff convenience. A CNA confirmed the resident's request but lacked the authority to change it. The DON was informed of these findings.
A resident with severe cognitive impairment lost his hearing aids, and despite his daughter's report to staff, the facility failed to investigate or update them. Staff interviews revealed a lack of awareness and communication, and the Licensed Social Worker only initiated an investigation after being informed by the surveyor.
The facility failed to provide timely assistance to residents, leading to prolonged waits for toileting help. A resident with quadriplegia was left in a fetal position for two hours without receiving a needed suppository. Another resident with cerebral infarction and diabetes reported frequent delays in receiving toileting assistance, sometimes waiting up to one and a half hours. A third resident with hemiplegia and spinal stenosis experienced a half-hour wait for help while on the toilet. Staff interviews suggested potential staffing inadequacies.
A resident with limited ROM did not receive a left hand splint as ordered by the physician. Despite multiple observations showing the resident with a contracture and no splint, staff interviews revealed a lack of awareness and documentation regarding the splint order. The Restorative team was responsible for applying the splint, but there was no record of its application in the electronic system.
A facility failed to provide adequate supervision during a Hoyer lift transfer, as a CNA used the lift without a second staff member, contrary to policy. Additionally, an oxygen tank was improperly stored beside a resident's bed, against facility policy. The resident required continuous oxygen therapy due to respiratory issues. Staff interviews revealed inconsistent practices in oxygen tank storage.
The facility failed to accurately reconcile controlled substances for two residents. One resident's Alprazolam administration was not documented in the controlled drug record, while another resident's Oxycodone administration was not recorded in the MAR. Staff interviews revealed lapses in following documentation protocols.
The facility failed to secure treatment and medication carts and did not dispose of expired medications. An unlocked treatment cart was observed in the Delta unit, and an LPN left a medication cart unattended during a resident altercation. Expired medications were found in a medication cart, despite regular checks by staff.
The facility failed to implement CDC guidelines for Enhanced Barrier Precautions for two residents with wounds. One resident lacked EBP guidelines in their care plan, and observations showed missing PPE and signposts. CNAs assisted the resident without gowns due to urgency and lack of PPE. Another resident also lacked EBP guidelines, with no signpost or PPE readily available. Staff relied on verbal reports for EBP adherence, indicating a failure in infection prevention and control.
The facility failed to maintain functional emergency call devices in two bathrooms on the Alpha Unit, with pull cords wrapped around grab bars and dragging on the floor. Staff interviews confirmed the cords should not be wrapped, and the DON acknowledged the absence of a policy on call devices.
The facility failed to follow physician's orders for wound treatment for two residents. One resident's dressing was not changed as required, and another resident had a skin tear dressing without a physician order. Both discrepancies were confirmed by staff and documented inaccurately.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address a significant weight loss in a timely manner for a resident, leading to a deficiency in providing adequate nutritional care. The resident, who had a history of right adrenalectomy, bipolar disorder, dementia, and hypertension, experienced multiple significant weight losses over a period of time. Despite these changes, the facility did not implement effective nutritional interventions or communicate effectively among the multidisciplinary team to address the resident's nutritional needs. The facility's policies required the dietitian to work closely with the interdisciplinary team to assess and address nutritional issues. However, the dietitian did not consistently attend risk meetings or communicate significant weight loss to the resident's practitioner or nursing staff. The resident's weight was monitored, but the dietitian's recommendations were not timely or sufficient to prevent further weight loss. The resident's nutritional supplements were reduced based on meal consumption, but this decision did not consider the ongoing weight loss. Interviews with staff revealed a lack of awareness and communication regarding the resident's severe weight loss. The nurse practitioner was not informed of the significant weight loss until it was visibly noticeable, and the dietitian did not contact the practitioner or nursing staff about the resident's condition. The facility's director of nursing and other staff members were aware of the weight loss but did not take appropriate action to address it. This lack of communication and timely intervention contributed to the deficiency in maintaining the resident's nutritional health.
Failure to Provide Fresh Fruit as Per Menu
Penalty
Summary
The facility failed to adhere to its own menu guidelines by not providing fresh fruit to residents as specified. Observations and interviews with eight residents revealed that they were not receiving fresh fruit daily as indicated on their meal tickets. Residents reported receiving fresh fruit, specifically bananas, only once or twice a week, contrary to the menu that promised fresh fruit for breakfast daily. This discrepancy was noted during breakfast observations in the main dining room and in residents' rooms. The residents involved in this deficiency were cognitively intact, as indicated by their Brief Interview of Mental Status (BIMS) scores of 15, except for one resident who was rarely or never understood. The facility's diet technician confirmed the weekly delivery of bananas and the substitution of other fresh fruits but could not explain why fresh fruit was not provided to all residents on the observed date. This failure to follow the menu affected residents with various diagnoses, including Hypokalemia, Hemiplegia, Depression, Dysphagia, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Type 2 Diabetes, Hypertension, Parkinson's, and Anxiety Disorder.
Facility Fails to Provide Palatable and Appetizing Meals
Penalty
Summary
The facility failed to provide palatable, appetizing, and flavorful food to eight residents, as observed through interviews and record reviews. Residents expressed dissatisfaction with the quality and taste of the food, describing it as bland, unappetizing, and inconsistent with their requests. For instance, one resident complained about the inconsistency in receiving eggs cooked to their preference, while another mentioned that meals were incomplete and did not match the menu. Additionally, a test tray revealed that the food lacked seasoning, color variation, and was served in an unappealing manner. Several residents, despite having varying levels of cognitive impairment, consistently reported that the food was not flavorful and did not meet their expectations. One resident with severe cognitive impairment stated that the food was horrible, while another with no cognitive impairment mentioned that the staff reacted negatively when complaints about the food were made. The residents' medical conditions, such as chronic kidney disease, amyotrophic lateral sclerosis, and diabetes, were noted, but the primary concern was the lack of appetizing and flavorful meals. The Food Service Director acknowledged that many residents were on a No Added Salt diet, which contributed to the bland taste of the food. However, the test tray was conducted on a Regular diet, indicating that the issue was not solely related to dietary restrictions. The deficiency in providing palatable meals was evident across multiple residents, regardless of their dietary needs or cognitive status, highlighting a systemic issue in the facility's food service operations.
Failure to Provide Correct Pureed Diet Consistency
Penalty
Summary
The facility failed to provide the correct diet consistency for nine residents who were prescribed a pureed consistency diet. Observations revealed that meals served to these residents were not smooth and contained lumps or solid particles, which is inconsistent with the requirements for a pureed diet. This issue was observed during multiple meal services, where residents were served pureed entrees that appeared lumpy and contained small pieces that required chewing. The Food Service Director acknowledged the inconsistency after a surveyor's observation and tasting of the meals. The facility's policy on pureed food consistency, which requires a smooth texture without solid particles, was not adhered to. Specific residents affected included those with conditions such as dysphagia and Parkinson's, who require a pureed diet to prevent complications with chewing or swallowing. For instance, one resident with Parkinson's and dysphagia was served a meal with visible pieces of corn, and another resident with dysphagia was served lumpy pureed corn. The Speech Language Pathologist confirmed that the pureed food should have a smooth consistency and expressed concern over the presence of solid particles in the meals served. The facility's failure to provide the correct diet consistency had the potential to affect 14 residents prescribed the pureed diet.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety and sanitary conditions, impacting 106 of 112 residents. During an initial kitchen tour, several deficiencies were noted, including the presence of personal food stored improperly in the walk-in refrigerator, debris on the floor of the Arctic walk-in freezer, and unclean equipment such as a metal backsplash with black and brown streaks, a clear plastic bin with dried residue, frying pans with burned debris, a large stock pot with black debris, and a meat slicer with rusty and brown residue. These observations indicate a lack of proper cleaning and maintenance of kitchen equipment and storage areas. Further issues were identified during a follow-up tour, where food temperatures were found to be above the safe standard of 41°F, with chocolate pudding at 48°F and puree Black Forest Cake at 54°F. Additionally, the nourishment rooms had unsanitary conditions, including brown residue on refrigerator shelves and door handles, and a microwave with brown residue on its interior surfaces. The refrigerator in the Delta Yellow nourishment room was also above the safe temperature at 44°F. Interviews with staff revealed a lack of clarity regarding cleaning responsibilities, contributing to the unsanitary conditions observed.
Failure to Honor Resident's Bedtime Preference
Penalty
Summary
The facility failed to honor a resident's choice regarding their preferred scheduled bedtime, as outlined in their care plan and interest assessments. The resident, who was admitted with Quadriplegia, C1-C4 incomplete, and had a BIMS score indicating no cognitive impairment, expressed that it was very important for them to choose their bedtime. Despite this, observations showed the resident was still in bed undressed late in the morning on multiple occasions. The resident expressed a desire to be out of bed by 10:00 AM, but was consistently left in bed until after 12:00 PM. The resident communicated this preference to the staff, but was told that the schedule was based on what was best for the nursing staff. A CNA confirmed the resident's request but stated she did not have the authority to change the schedule. The Director of Nursing was informed of these findings.
Failure to Address Grievance Regarding Lost Hearing Aids
Penalty
Summary
The facility failed to address a grievance regarding the loss of hearing aids for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including Traumatic Subdural Hemorrhage and Major Depressive Disorder, reported losing his hearing aids two weeks prior to the survey. Despite the resident's daughter reporting the loss to both laundry and nursing staff, no action was taken to investigate or resolve the issue, and the resident was not updated on the status of his hearing aids. Interviews with staff revealed a lack of awareness and communication regarding the resident's grievance. A Certified Nursing Assistant (CNA) and a Charge Licensed Practical Nurse (LPN) were unaware of the resident's loss of hearing aids. The Licensed Social Worker (LSW) explained the facility's process for reporting lost items, which involves completing a Care and Concern form and initiating an investigation. However, no such form was completed for the resident's hearing aids, indicating a breakdown in the reporting process. The resident's daughter expressed concern about her father's difficulty in communicating due to the loss of his hearing aids. Despite her efforts to report the issue, she received no updates from the facility staff. The LSW acknowledged the reporting failure and initiated the investigation only after being informed by the surveyor. This deficiency highlights the facility's failure to adhere to its grievance policy and promptly address resident concerns.
Failure to Provide Timely Assistance to Residents
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for three residents. Resident #114, who has quadriplegia, was left in a fetal position on his bed for two hours waiting for a suppository that was never administered. This incident was discovered by a CNA who found the resident sweating and with a racing heart, and subsequently assisted him to the bathroom. Resident #34, who has a history of cerebral infarction and diabetes, reported during a resident council meeting that he frequently waits too long for toileting assistance, sometimes up to one and a half hours, despite using the call bell and contacting the front desk for help. Resident #104, who has hemiplegia and spinal stenosis, also reported waiting for half an hour for assistance while on the toilet. A CNA informed him that she could not assist because she was assigned to a different section. Interviews with staff revealed that each CNA was responsible for seven residents, and while they believed they could manage with love and cooperation, there was an implication of insufficient staffing to meet residents' needs promptly. These incidents highlight a failure to provide timely and adequate care, as required by professional standards.
Failure to Apply Left Hand Splint as Ordered
Penalty
Summary
The facility failed to provide a left hand splint as per the physician's order for a resident with limited range of motion. The resident, who was readmitted with diagnoses of hypertension and muscle weakness, had an order dated 11/30/23 to apply a left hand splint and left elbow protector for 8 hours during AM hours. Observations on multiple occasions revealed that the resident was in bed with a contracture on the left hand and no splint in place. The resident confirmed that the splint had not been applied, and staff interviews indicated a lack of awareness and documentation regarding the splint order. Interviews with the facility's Rehab Director, Registered Nurse, and Restorative Certified Nursing Assistant revealed a breakdown in communication and responsibility for ensuring the splint was applied. The Restorative team was responsible for overseeing the placement of splints, but there was no documentation in the electronic system for the resident's splint application. The Restorative CNA was unaware of the order for the left hand splint, and the Registered Nurse confirmed that no documentation was present for the splint's application in the last 14 days. The Director of Nursing was informed of these findings.
Inadequate Supervision and Oxygen Tank Storage Deficiencies
Penalty
Summary
The facility failed to provide adequate supervision during a Hoyer lift transfer for a resident, which was observed when a Certified Nursing Assistant (CNA) used the mechanical lift to lower the resident into bed without the assistance of another staff member, contrary to the facility's policy. The policy requires at least two people to assist during mechanical lift transfers. The CNA acknowledged the difficulty in finding additional staff to assist during busy times, such as breakfast, which led to the unsupervised transfer. This deficiency had the potential to affect 50 residents who used Hoyer lifts in the facility. Additionally, the facility failed to ensure that an oxygen tank was properly secured for another resident. Observations revealed that an additional oxygen tank was standing next to an empty holder beside the resident's bed, contrary to the facility's policy that requires all portable oxygen tanks not in use to be secured and stored in the designated oxygen storage room. Interviews with staff members indicated a lack of consistent practice regarding the storage of oxygen tanks, with some staff stating that extra tanks should not be kept at the bedside and should be returned to the oxygen room when empty. The resident involved in the oxygen tank deficiency had a history of respiratory issues, including COPD and acute respiratory failure, and required continuous oxygen therapy. Despite the facility's policy and the resident's care plan, the unsecured oxygen tank posed a potential hazard. The inconsistency in staff practices regarding the storage of oxygen tanks highlights a gap in adherence to the facility's safety protocols.
Controlled Substance Reconciliation Failures
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled substance medications for two residents. For one resident, there was a discrepancy in the documentation of Alprazolam administration. The resident's controlled drug record sheet did not reflect the removal of a tablet on a specific date, although the electronic Medication Administration Record (eMAR) indicated it was administered. The Licensed Practical Nurse (LPN) involved acknowledged the oversight, stating she missed documenting the removal in the controlled drug record. The Director of Nursing expressed confusion over the inconsistency between the eMAR and the controlled drug binder. For another resident, there was a failure to document the administration of Oxycodone in the Medication Administration Record (MAR), despite it being signed out on the Controlled Drug Record. The Registered Nurse (RN) confirmed the correct count of the medication, but the administration was not recorded in the MAR. Interviews with nursing staff, including the Director of Nursing, revealed that the protocol requires documentation in both the Controlled Drug Record and the MAR, which was not followed in this instance.
Medication and Treatment Cart Security and Expired Medications
Penalty
Summary
The facility failed to ensure the security of treatment and medication carts, as well as the proper disposal of expired medications. During an initial tour, a treatment cart in the Delta unit was found unlocked and unattended, containing treatment medications labeled with residents' names and a pair of scissors. This cart remained unlocked for an extended period, despite multiple staff members and residents passing by. Additionally, during a medication administration observation, an LPN left a medication cart unlocked and unattended for approximately seven minutes while addressing a potential altercation between two residents. The dispensed medication for a resident was left on top of the cart during this time. Furthermore, a review of medication storage revealed expired over-the-counter medications in a medication cart in the Delta Yellow unit. The expired medications included an antacid and a cough syrup, both past their expiration dates. Staff E, a Senior LPN, expressed surprise at finding expired medications, despite regular checks by the pharmacist and unit nurse supervisor. The Delta Unit Nurse Supervisor confirmed that random checks are conducted, and floor nurses are responsible for checking expiration dates before administering medications.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds
Penalty
Summary
The facility failed to implement CDC guidelines for Enhanced Barrier Precautions for two residents with wounds. Resident #61, who was readmitted with multiple diagnoses including wounds on the right and left heels, did not have Enhanced Barrier Precautions (EBP) guidelines included in their care plan. Observations revealed the absence of EBP signposts on the resident's door and a lack of personal protective equipment (PPE) such as gowns and gloves on the metal shelf. During an incident, two CNAs assisted the resident with toileting without wearing gowns, citing the absence of gowns on the shelf and urgency as reasons. Interviews with staff revealed a lack of clarity on who was responsible for replenishing PPE and the omission of EBP guidelines in the care plan. Similarly, Resident #101, admitted with end-stage renal disease and sacral pressure ulcers, also lacked EBP guidelines in their care plan. Observations showed no EBP signpost or PPE shelf on the resident's door. A wound care RN had to request a PPE gown before entering the resident's room, indicating a lack of readily available PPE. Interviews with staff highlighted that the wound care RN had placed the PPE cart, but there was no EBP signpost, and staff relied on verbal reports to know when EBP guidelines should be followed. These deficiencies indicate a failure to adhere to CDC recommendations for infection prevention and control in the care of residents with wounds.
Deficiency in Emergency Call Device Functionality
Penalty
Summary
The facility failed to ensure that the emergency call devices in the bathrooms of the Alpha Unit were functioning properly. Observations revealed that in two of the twelve bathrooms, the emergency call device pull cords were wrapped around the grab bars, rendering them non-functional. Photographic evidence was obtained to document these findings. Interviews with staff members, including CNAs and RNs, confirmed that the pull cords should not be wrapped around the grab bars, indicating a lack of adherence to proper protocol. Further investigation revealed that the facility did not have a policy in place regarding the proper use and maintenance of emergency call devices. The Director of Nursing confirmed the absence of such a policy during an interview. The Registered Nurse Supervisor acknowledged the issue during a side-by-side observation with the surveyor and attempted to rectify the situation by unwrapping the cords, which were found to be excessively long and dragging on the floor. This deficiency highlights a gap in the facility's procedures for ensuring resident safety in bathroom areas.
Failure to Follow Physician's Orders for Wound Treatment
Penalty
Summary
The facility failed to follow the physician's orders for wound treatment for two residents. Resident #4, who had diagnoses including Non-Traumatic Intracerebral Hemorrhage, Encephalopathy, Unsteadiness on Feet, Diabetes Mellitus, and an Unspecified Open Wound on the Lower Leg, was supposed to have his left lower leg dressing changed every other day as per physician's orders. However, observations revealed that the dressing was dated 04/18/24, indicating it had not been changed as required. The Wound Care Nurse and a Registered Nurse confirmed the discrepancy, and the Treatment Administration Record falsely documented that the dressing had been changed on 04/20/24 and 04/22/24. Resident #5, who had diagnoses including Atrial Fibrillation, Diabetes Mellitus, Venous Insufficiency, Cellulitis of the Left Toe, Localized Swelling, Acute Osteomyelitis, and an Open Wound of the Left Foot, had a skin tear on the left shin with a Xeroform gauze dressing. However, there was no physician order for this treatment. The Wound Care Nurse was unaware of the skin tear, and the Director of Nursing confirmed the absence of a physician order for the dressing. An RN later stated that an order for the skin tear was obtained on the day of the surveyor's observation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pembroke Pines
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Memorial Manor | 0.7 mi | ★★★★★ | 1 | 0 |
| Emerald Nursing And Rehabilitation Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Sierra Lakes Nursing & Rehabilitation Center | 4.9 mi | ★★★★★ | 11 | 1 |
| Gardens Nursing And Rehab Center | 5.1 mi | ★★★★★ | 26 | 0 |
| Nspire Healthcare Miami Lakes | 5.9 mi | ★★★★★ | 7 | 0 |
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