Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Broward Oaks Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with a history of a healed sacral wound did not receive timely preventive interventions such as an air mattress and wedge cushions, despite being at risk for pressure ulcers and dependent on staff for care. Preventive measures were delayed for several weeks, and weekly skin assessments were not consistently performed or documented by the LPN. The resident subsequently developed a stage 4 pressure ulcer, with staff interviews revealing inconsistent monitoring and delayed response to the resident's changing condition.
The facility did not follow professional standards or its own policies for indwelling urinary catheter care for two residents, including delayed initiation of Enhanced Barrier Precautions, inconsistent catheter securement, lack of timely care plan updates, and poor infection control practices such as failure to change gloves and perform hand hygiene. One resident developed a UTI and required antibiotic treatment.
A resident with multiple chronic conditions experienced severe, unaddressed weight loss due to the facility's failure to promptly identify and intervene according to policy. Despite eating most meals and expressing willingness to take supplements, the resident's significant weight loss was not acted upon by the clinical dietitian, and inconsistent weight monitoring practices, including use of uncalibrated scales, contributed to the deficiency.
The facility failed to accurately document comprehensive assessments for four residents, resulting in discrepancies between the MDS, care plans, and medical records regarding diagnoses, vision status, and oxygen use. Staff interviews and record reviews revealed that some residents were incorrectly coded for certain diagnoses or lacked documentation of significant conditions such as legal blindness, PTSD, and oxygen therapy.
The facility failed to consistently implement fall prevention and elopement policies, resulting in one resident leaving the premises without authorization and another experiencing an unwitnessed fall with delayed physician notification and inconsistent use of fall interventions such as floor mats. Staff interviews revealed gaps in knowledge and training regarding emergency alarms and care plan adherence.
A resident with an indwelling urinary catheter was observed multiple times with the catheter tubing unsecured to the leg, despite care plan interventions requiring it to be secured every shift. CNAs performed catheter care without securing the tubing, and both staff and the DON acknowledged the expectation to follow care plan interventions, but the required practice was not followed.
Surveyors found that the facility did not consistently follow physician orders for oxygen therapy, failed to document oxygen use accurately in the MDS, and did not ensure respiratory equipment was changed and dated as required. Several residents with respiratory conditions either did not receive prescribed oxygen, received it inconsistently, or had care plans and documentation that did not reflect their actual therapy.
The facility failed to ensure accurate management and documentation of controlled substances, including discrepancies in medication records, failure to remove discontinued medications, and inconsistencies between the controlled drug record and the MAR. Staff and the DON acknowledged these issues, which affected several residents with complex medical and psychiatric conditions.
The facility did not properly monitor or document behaviors and side effects for residents prescribed psychotropic medications and anticoagulants. Despite care plans and physician orders requiring observation of symptoms and adverse reactions, staff failed to record this information in the MAR/TAR, and pharmacy audits did not confirm monitoring. Interviews revealed that staff believed monitoring was occurring, but no evidence was provided, and adverse events such as falls were not consistently linked to medication side effects.
A resident with diabetes received multiple doses of Novolog insulin from a flex pen that had been used beyond the recommended 28-day expiration period. An LPN, unaware of the correct expiration timeframe, administered the expired insulin before the issue was identified during a medication pass observation. Facility policy and pharmacy guidance both required disposal of the insulin after 28 days, but this was not followed.
Two residents were found with unsecured medications and supplements at their bedsides, including prescription ointment and multiple over-the-counter products, without physician orders or approval for self-administration. Staff confirmed that facility policy prohibits medications at the bedside unless specifically assessed and ordered, but these requirements were not followed.
Pureed pancakes served to residents on a pureed diet were observed to be lumpy, grainy, and sticky, rather than having the required smooth and uniform texture. This issue was identified during a kitchen observation and confirmed by a SLP, potentially affecting 20 residents receiving pureed diets.
Multiple lapses in food service safety and sanitation were observed, including staff not wearing facial hairnets, improper thawing of raw ground beef, exposed cooked vegetables, lack of proper sanitizing solution for cleaning rags, storage of dirty items on clean equipment, undated and unlabeled chef salads, and the use of a food thermometer without gloves.
Staff failed to follow Enhanced Barrier Precautions (EBP) for two residents with indwelling devices, including not wearing gowns during catheter care and lacking EBP signage for a resident receiving tube feeding. Multiple staff members were unaware of EBP requirements or which residents qualified, and EBP signage and supplies were inconsistently available or visible.
Delayed Pressure Ulcer Prevention and Inadequate Monitoring
Penalty
Summary
The facility failed to adhere to professional standards for the care and management of pressure ulcers for one resident. Upon admission, the resident had a history of a healed sacral wound with no open areas or drainage, and the initial skin assessment did not identify any current pressure ulcers. Despite being dependent on staff for most activities of daily living and having multiple comorbidities, preventive interventions such as an air mattress and wedge cushions were not implemented until several weeks after admission. The care plan for skin integrity was initiated, but specific interventions for pressure ulcer prevention were delayed, with the air mattress ordered approximately four weeks after admission and the wedge cushion about seven weeks after admission. Interviews with the wound care LPN revealed that although the resident was identified as being at risk for pressure ulcers, preventive measures were not immediately provided because there was no open wound at admission. The LPN admitted to not performing weekly skin assessments as required and only reassessed the resident after being notified of skin breakdown. Documentation was inconsistent, with late entries in the nursing progress notes, and the LPN acknowledged not knowing why weekly skin notes were not completed. The resident's condition deteriorated, and within a month, a stage 4 pressure ulcer developed, which the LPN stated was unusual for a resident with no initial skin openings. Additional staff interviews indicated that while some preventive measures such as barrier creams and frequent repositioning were reportedly followed, there was a lack of consistent monitoring and oversight of these interventions. The staff also noted the resident's frequent refusal of care, but could not specify when this behavior began. The delay in implementing appropriate preventive measures and inconsistent documentation and monitoring contributed to the development and worsening of the resident's pressure ulcer.
Failure to Follow Catheter Care Standards and Infection Control Practices
Penalty
Summary
The facility failed to adhere to professional standards and its own policies regarding the care and management of indwelling urinary catheters for two residents. For one resident, the facility did not initiate Enhanced Barrier Precautions (EBP) as required by its policy for residents with indwelling medical devices, delaying implementation for approximately seven weeks after catheter placement. Additionally, catheter care was not documented as performed every shift as ordered, and the catheter was not consistently secured with a holder to prevent migration, as required by physician orders and facility policy. For another resident, observations revealed that the urinary catheter was not secured to the thigh and was freely moving, with the securement device not attached or dated. Staff interviews confirmed that catheter securement was inconsistently performed, with CNAs indicating that reattachment was the responsibility of nurses and that they reported detachment to nursing staff. During care observations, a CNA failed to change gloves between tasks, using the same gloves to clean the resident, handle the catheter tubing, and touch various surfaces and items, which is inconsistent with infection control standards. The resident also reported that staff did not perform hand hygiene before providing urinary care. Record reviews showed that catheter care was not initiated in the care plan until several days after the physician's order for catheter placement, and EBP interventions were not included in the care plan. Documentation also indicated that catheter securement was not performed on specific shifts as required. One resident developed a urinary tract infection, for which antibiotic treatment was ordered. Staff interviews revealed inconsistent practices regarding the timing and performance of catheter care, as well as monitoring for signs of infection.
Failure to Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to identify and address a significant weight loss in a timely manner for a resident with multiple medical conditions, including Type 2 Diabetes, End Stage Renal Disease, Anemia, and dependence on dialysis. The facility's policy required prompt re-weighing, notification of the dietitian, and intervention when significant weight loss was detected. Despite these protocols, the resident experienced a 7.5% severe weight loss over a six-week period, which was not addressed by the clinical dietitian or reflected in the nutrition progress notes. The resident's care plan indicated a need to maintain weight within a specific range and to receive dietary evaluation and changes as needed, but these actions were not taken when the weight loss occurred. Observations and interviews revealed that the resident was eating 75-80% of meals and was cognitively intact, able to express preferences and concerns about food choices. The resident reported a decreased appetite and a willingness to consume nutritional supplements, but there was no evidence that additional supplements or interventions were provided after the significant weight loss was identified. The facility's documentation showed inconsistencies in weight monitoring practices, with weights being taken by both facility staff and the dialysis team, sometimes using uncalibrated or malfunctioning scales. This led to discrepancies in recorded weights and confusion about the resident's actual nutritional status. Further compounding the issue, communication between staff members regarding significant weight changes was inconsistent. The dietary technician and CNAs described different processes for weight monitoring and reporting, and the clinical dietitian was not notified or did not respond to the severe weight loss in a timely manner. The facility administrator acknowledged issues with scale accuracy and had recently arranged for calibration, but this action occurred after the deficiency was identified. As a result, the resident continued to lose weight, dropping to 80% of ideal body weight, without appropriate assessment or intervention from the clinical team.
Inaccurate Documentation of Resident Assessments
Penalty
Summary
The facility failed to ensure accurate documentation of comprehensive assessments for four residents, specifically regarding diagnoses, vision, and oxygen use. For one resident, the Minimum Data Set (MDS) included a diagnosis of schizophrenia, despite no supporting documentation in the medical or psychiatric records. The MDS Registered Nurse acknowledged this discrepancy during a side-by-side review of the resident's records. Another resident's MDS assessment did not reflect the use of oxygen or impaired vision, even though physician orders, care plans, and direct observation confirmed the use of oxygen therapy and a diagnosis of legal blindness. The MDS Coordinator was informed of these inconsistencies but did not provide an immediate explanation for the discrepancies. A third resident's MDS assessment omitted a diagnosis of Post Traumatic Stress Disorder (PTSD), despite it being listed among the resident's medical diagnoses. Interviews with various staff members, including CNAs and nurses, revealed a lack of awareness or documentation regarding the resident's PTSD triggers. The MDS Coordinator confirmed that PTSD should be documented in Section I of the MDS but acknowledged the omission and noted that other MDS Coordinators were not present to address the issue. For the fourth resident, the MDS assessment indicated adequate vision and clear speech, while the care plan documented impaired communication and vision loss due to glaucoma and cataracts. Interviews with the MDS Coordinator and Social Services Director revealed conflicting assessments of the resident's vision status, with the care plan and medical history indicating impairment, but the MDS and social services staff reporting adequate vision. These inconsistencies demonstrate a failure to accurately assess and document residents' conditions in the MDS, as required.
Failure to Prevent Elopement and Inconsistent Fall Prevention Measures
Penalty
Summary
The facility failed to follow its own policies regarding fall prevention and elopement, resulting in deficiencies related to accident hazards and inadequate supervision. In one instance, a resident with a history of hydrocephalus, dementia, and other medical conditions was able to leave the facility without authorization during the night. Staff last observed the resident in bed during routine checks, but later discovered the resident missing after an alarm sounded. The nurse on duty was unfamiliar with the alarm system and did not immediately recognize the significance of the alarm sounds, delaying the response. The resident was eventually found outside the facility by police and returned unharmed. Interviews revealed that not all staff were clear on the alarm system's operation or had participated in elopement drills as required by facility policy. In another case, a resident with severe cognitive impairment and multiple risk factors for falls experienced an unwitnessed fall. The resident was found on the floor by staff during a midnight round and was unable to be oriented to reality. Documentation showed that the physician was not notified of the fall until more than 24 hours after the incident, contrary to facility policy which requires immediate notification. Additionally, the resident's care plan included the use of floor mats as a fall intervention, but observations revealed inconsistent implementation of this intervention. The resident's family member reported having to place a floor mat herself, indicating lapses in staff adherence to the care plan. These events demonstrate that the facility did not consistently implement or monitor required interventions for fall prevention and elopement risk. Staff interviews highlighted gaps in knowledge and training regarding emergency procedures and the use of safety equipment. The lack of timely physician notification and inconsistent application of care plan interventions contributed to the deficiencies identified during the survey.
Failure to Secure Indwelling Urinary Catheter as Required by Care Plan
Penalty
Summary
The facility failed to follow its policy and care plan interventions for urinary catheter care for a resident with multiple diagnoses, including neurogenic bladder and chronic kidney disease. The resident had an indwelling urinary catheter, and the care plan specified that the catheter should be secured to the leg every shift to prevent migration and accidental dislodgement. Multiple observations over several days revealed that the catheter tubing was not secured to the resident's leg as required. Certified Nursing Assistants (CNAs) performed catheter care without securing the catheter tubing, and both CNAs confirmed that the tubing was not secured. After providing care, they still did not secure the catheter tubing to the resident's leg. Additionally, the Director of Nursing (DON) stated that nurses are educated to follow care plan interventions, but the observations and staff interviews indicated that the care plan was not being followed in practice. The failure to secure the catheter tubing as outlined in the care plan and facility policy constituted a deficiency in providing appropriate catheter care and in preventing potential catheter-related complications.
Failure to Follow Physician Orders and Document Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders and provide safe and appropriate respiratory care for all eight sampled residents requiring oxygen therapy or respiratory support. Surveyors observed that oxygen therapy was not administered as ordered, with several residents either not receiving oxygen when prescribed, or receiving it inconsistently. In multiple cases, oxygen tubing and nebulizer equipment were not dated or changed according to physician orders or facility policy, and documentation in the Minimum Data Set (MDS) assessments was inaccurate or incomplete for residents receiving oxygen therapy. For example, one resident with diagnoses including heart failure and COPD had physician orders for oxygen therapy as needed to maintain oxygen saturation above 93%, but the care plan did not include goals or interventions for oxygen therapy, and the MDS did not reflect oxygen use despite documented administration. Another resident with heart failure and pneumonia was observed receiving oxygen, but the tubing was not dated, and the MDS assessment did not indicate oxygen therapy. Similar issues were found with other residents, including missing or outdated documentation of oxygen and nebulizer tubing changes, lack of care plan interventions, and discrepancies between observed care and physician orders. Additionally, some residents were not provided with the prescribed oxygen therapy at all, as observed in the case of a resident with an order for continuous oxygen who was repeatedly found without oxygen equipment in her room. Staff interviews revealed inconsistent knowledge and practices regarding the frequency of changing and dating respiratory equipment, and MDS coordinators were unable to verify the accuracy of assessments for residents under their care. These findings demonstrate a pattern of noncompliance with physician orders, inadequate documentation, and failure to ensure safe and appropriate respiratory care for residents requiring oxygen therapy.
Failure to Accurately Manage and Document Controlled Substances
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to ensure the accurate acquisition, receipt, dispensing, administration, and recordkeeping of medications, particularly controlled substances, for several residents. In one instance, a resident with severe cognitive impairment had a discontinued order for Clonazepam that remained in the medication cart, and the medication label did not match the order in the resident's medical record. Both the RN and the DON acknowledged that the medication should have been removed when discontinued, and that the documentation on the medication bingo card and control record did not align with the physician's order. For another resident with multiple psychiatric diagnoses, a review of the controlled substance record for Clonazepam revealed discrepancies in the documentation of the number of tablets on hand and those administered, with no explanation for the inconsistencies. Similarly, a resident with diabetes and other complex conditions had discrepancies in the administration and documentation of Tramadol, including tablets being removed from the controlled substance box without corresponding documentation on the Medication Administration Record (MAR), and instances where more tablets were removed than documented as administered. The staff involved were unable to explain these discrepancies during interviews. Additionally, a resident with a recent femur fracture and good cognitive status had a controlled drug signed out as administered, but there was no documentation in the MAR to confirm administration. Staff interviews confirmed that the expected process is to document administration both on the controlled drug record and the MAR, but this was not done. The DON acknowledged that reconciliation of controlled substances is supposed to occur at every shift change, but the observed discrepancies indicate this was not consistently followed.
Failure to Monitor Behaviors and Side Effects for Residents on Psychotropic Medications and Anticoagulants
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs by not accurately monitoring behaviors and side effects for residents prescribed psychotropic medications and anticoagulants. Multiple residents with diagnoses such as dementia, depression, anxiety, and psychotic disorders were prescribed medications including antidepressants, antipsychotics, and anticoagulants. Despite care plans and physician orders specifying the need for monitoring of targeted symptoms, behaviors, and adverse drug reactions, there was a lack of documented evidence in the Medication Administration Records (MAR) and Treatment Administration Records (TAR) that such monitoring was performed. For several residents, including those with severe cognitive impairment and complex psychiatric and medical histories, the required monitoring for both the effectiveness and side effects of psychotropic medications was not documented. In some cases, care plans outlined specific symptoms and behaviors to be observed, such as changes in mood, appetite, involuntary movements, and signs of bleeding for those on anticoagulants. However, reviews of the MAR/TAR revealed either no documentation or only check marks indicating medication administration, without any indication that behaviors or side effects were assessed or recorded as required. Interviews with nursing staff, pharmacy consultants, and the Director of Nursing confirmed that while staff believed monitoring was being conducted and documented electronically, they were unable to provide evidence of this documentation. Additionally, pharmacy audits did not verify the presence of behavior or side effect monitoring, and staff were often unaware of the frequency or details of adverse events such as falls, which could be related to medication side effects. This lack of monitoring and documentation was consistent across all sampled residents receiving psychotropic medications and anticoagulants.
Expired Insulin Administered to Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to the administration of expired insulin. During a medication administration observation, an LPN prepared to administer Novolog insulin from a flex pen that had been opened and used beyond its manufacturer-recommended expiration period of 28 days. The LPN initially stated that all insulin in the facility expired in 35 to 45 days, but upon review of the label, acknowledged that the insulin had expired and confirmed that doses had been administered to the resident after the expiration date. The LPN then obtained a new insulin pen before proceeding with the administration. The resident involved had a history of obstructive sleep apnea, hypertension, and type 2 diabetes mellitus with diabetic neuropathy, and had a physician's order for Novolog insulin per sliding scale. The facility's policy and the pharmacist consultant both confirmed that Novolog insulin should be discarded after 28 days at room temperature. Review of the medication administration record showed that the resident had received multiple doses of Novolog insulin after the pen's expiration date, indicating a failure to adhere to both facility policy and manufacturer guidelines regarding medication expiration.
Failure to Secure and Store Medications Properly
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly secured and stored in accordance with professional standards for two residents. For one resident with a diagnosis of Type 2 Diabetes Mellitus and a BIMS score indicating intact cognition, a tube of prescription Mupirocin ointment 2% was observed on the dresser in plain sight on two separate occasions. There was no physician's order for this medication, nor an order permitting self-administration. Staff confirmed that medications should not be kept at the bedside unless the resident has been assessed and approved for self-administration, which was not the case for this resident. In another instance, a different resident with similar diagnoses and cognitive status was found to have four large bottles of over-the-counter supplements, including Calcimate Plus with Magnesium and Vitamin D-3, Magnesium Citrate, Probiotic gummies, and High-Metabolite Immunogens, unsecured and accessible on the bedside table. The resident reported that her daughter brought the supplements, but she had not taken them and was unaware of any physician's order for their use. Record review confirmed there were no orders for these supplements or for self-administration, and the care plan did not address self-administration. Staff interviews indicated that medications at the bedside should be confiscated and held for family pickup, and the assigned nurse was unaware of the presence of these supplements.
Failure to Provide Proper Pureed Food Consistency for Residents
Penalty
Summary
During an observation in the facility's central kitchen, pureed pancakes prepared for residents on a pureed diet were found to have a lumpy and grainy texture, rather than the required smooth consistency. The food was also noted to be firm and sticky when tested with a spoon, which does not meet the International Dysphagia Diet Standardization Initiative guidelines for pureed foods. The cook responsible for preparing the meal acknowledged the issue and indicated that a new blender would be used to achieve the correct consistency. The Speech Language Pathologist confirmed that pureed foods should have a uniform, smooth texture similar to pudding, applesauce, or hummus. This deficiency had the potential to affect 20 residents out of 98 who were on a pureed diet.
Food Service Sanitation and Safety Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety and sanitation during multiple observations in the main kitchen. The Dietary Service Manager and a diet aide were observed walking in the food production area without facial hairnet protection on several occasions. Raw ground beef was left thawing in a sink without running water, and a metal container of cooked vegetables was found partially opened and exposed in the reach-in refrigerator. Additionally, a dirty, used rag was stored in a red bucket without sanitizing solution, and empty food boxes and dirty gloves were placed on top of a clean pot in the food production area. Two plates of chef salad in the refrigerator were not dated or labeled. The Dietary Service Manager was also seen using a thermometer to check food temperatures without wearing gloves, further compromising food safety protocols.
Failure to Follow Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to follow Enhanced Barrier Precautions (EBP) guidelines for two residents who required such precautions due to the presence of indwelling medical devices. For one resident with hemiplegia, muscle weakness, aphasia, diabetes, dysphagia, and chronic kidney disease, staff were observed performing urinary catheter care without donning gowns as required by EBP protocols. Both CNAs involved only wore gloves and admitted to forgetting to wear gowns, despite EBP signage and supplies being available in the resident's room. Additionally, the catheter care procedure did not follow the facility's policy, as the CNA wiped the catheter tubing before the perineal area and used the same gloves throughout the process, including for handling supplies and applying ointment. For another resident with muscle weakness, dysphagia, expressive language disorder, and adult failure to thrive, who was receiving tube feeding, there was no EBP signage posted in the room or on the door. Multiple staff members, including a registered nurse and two CNAs, were unaware of which residents required EBP or the criteria for implementing EBP. The registered nurse, who was responsible for residents with devices such as a dialysis access port, did not recognize the need for EBP and could not identify the location of necessary supplies or signage. Observations confirmed the absence of EBP signage for residents with qualifying devices, and staff interviews revealed a lack of knowledge regarding EBP requirements. The infection preventionist confirmed that EBP should be implemented for all residents with devices such as PEG tubes, dialysis ports, tracheostomies, colostomies, or wounds, and that staff must wear gowns and gloves during care. The infection preventionist also acknowledged the absence of required EBP signage for the resident receiving tube feeding and confirmed that staff education on EBP was lacking at the time of the survey.
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What surveyors actually found near you
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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 Plantation
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Covenant Village Care Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Nspire Healthcare Plantation | 1.9 mi | ★★★★★ | 0 | 0 |
| Plantation Nursing & Rehabilitation Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Nspire Healthcare Lauderhill | 3.2 mi | ★★★★★ | 0 | 0 |
| Regents Park Of Sunrise | 3.9 mi | ★★★★★ | 4 | 1 |
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