Below 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 Childrens Comprehensive Care Center Inc during CMS and state inspections, most recent first.
A RN administered insulin from a vial that lacked an open-date label, contrary to facility policy requiring all opened insulin to be dated. During a med pass, the nurse retrieved an unlabeled insulin vial, confirmed she believed she was allowed to use it and had done so previously, and then administered the dose to a resident with multiple complex conditions, including endocrine and metabolic disease and COPD. Other RNs and the DON reported that their practice is to ensure all insulin vials are labeled with opening dates and that they would not administer insulin from an unlabeled vial, highlighting a discrepancy between stated policy and observed practice.
Surveyors identified multiple deficiencies in food storage and kitchen sanitation, including undated and expired food items, visible spoilage, and unsanitary equipment and surfaces. These issues had the potential to affect all residents receiving oral diets, as confirmed by staff during the inspection.
A facility failed to notify a resident's representative about a significant change in the resident's skin condition. The resident, who was medically fragile, developed sores that were not communicated to the representative, despite facility policies requiring such notification. The lack of documentation and communication was acknowledged by the DON, highlighting a deficiency in compliance with regulatory requirements.
The facility failed to develop care plans for ADLs for two residents and a skin impairment care plan for another, despite their dependence on staff. Additionally, seizure precautions were not followed for a resident, as bed rails lacked required padding. Staff acknowledged inconsistencies and unavailability of necessary equipment.
The facility failed to ensure proper use of Enhanced Barrier Precautions and hand hygiene during high-contact resident care activities. Staff were observed not wearing appropriate PPE, such as gowns, and there was confusion due to inconsistent signage. Additionally, hand hygiene lapses were noted during medication administration, and some staff did not adhere to the facility's policy on nail length.
A facility failed to assist a resident with feeding in a dignified manner. The resident, who was dependent on staff for all ADLs and had a care plan due to dysphagia, was observed being assisted with a meal by a staff member standing over them. This was not in line with promoting dignity, and the concern was acknowledged by the Activities Director.
The facility failed to provide proper fingernail grooming for four residents who were dependent on staff for ADLs. Observations showed long, jagged fingernails with black matter underneath, indicating a lack of hygiene care. Staff were unclear about responsibility for nail care, leading to inadequate grooming for residents with complex medical conditions.
A facility failed to obtain a physician order for pressure injury care for a resident and did not administer medications within prescribed time frames for several residents. A nurse performed wound care without authorization, and medication administration was delayed due to staffing issues. Additionally, a resident's tube feeding was not connected on time, leading to further delays in care.
Two residents with complex medical needs did not receive the prescribed enteral nutrition and water flushes as per physician orders. Observations revealed issues with feeding pump operation and labeling, leading to insufficient nutrition and hydration. The Consultant Registered Dietitian confirmed the discrepancies and acknowledged the need for further staff education.
The facility failed to assess and obtain informed consent for bed rail use for two residents who were dependent on staff for ADLs and had multiple medical conditions. Despite care plans indicating the use of bed rails for safety, there were no documented assessments, physician's orders, or consents. The facility's administration acknowledged these omissions during an interview.
A medication error rate of 14% was identified in an LTC facility, exceeding the acceptable 5% threshold. A resident with multiple complex medical conditions experienced late administration of medications, including Phenobarbital and Propranolol, by an RN. The RN acknowledged the delay, and the DON was informed of the issue.
The facility failed to secure medication and respiratory therapy carts, leading to unauthorized access. Expired biologicals were not removed, and medications requiring refrigeration were left out at improper temperatures. Additionally, improper disposal of medications was observed, with staff flushing medications down the toilet and discarding pills in regular trash. The facility's policies on medication storage and disposal were not consistently followed.
The facility failed to ensure qualified oversight of kitchen operations, affecting meal preparation for residents. A resident received improperly prepared pureed meals, with food items pooling on the plate and lacking proper consistency. The Food Service Manager was not a Certified Dietary Manager, and the Registered Dietitian was only present weekly, leaving the Operations Officer, who lacked food service management qualifications, to supervise the kitchen.
A facility failed to provide meals consistent with a resident's dietary orders for a pureed diet. The resident was observed receiving meals that were not properly prepared, with food items pooling on the plate and containing chunks. The Food Service Manager confirmed the meals were not prepared according to the recipe or dietary needs.
The facility's assessment inaccurately documented the qualifications and staffing requirements for the dietitian and omitted the requirement for a Director of Food and Nutrition Services. The Workforce Profile incorrectly listed the education level for a dietitian as a 'High School Diploma.' This was acknowledged during an interview with the Administrator and other staff.
Failure to Label Opened Insulin Vial Before Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy requiring that opened insulin vials be labeled with the date they are opened. The facility’s written policy on insulin administration, dated 06/15/20 and reviewed on 07/20/25, specifies that opened insulin must be labeled with the date. During a medication administration observation, a RN (Staff E) retrieved an insulin vial that did not have an open date on the label. When questioned, Staff E stated that she was allowed per facility policy to administer insulin without an open date and acknowledged that she had administered insulin from vials without open date labels before. She then drew up insulin based on the resident’s blood sugar reading and administered it to Resident #3 using this unlabeled vial. Resident #3’s record showed admission on a specified date with diagnoses including Disseminated Intravascular Coagulation (Defibrination Syndrome), a personal history of endocrine and metabolic diseases, peritoneal abscess, and COPD with acute exacerbation. The most recent MDS assessment documented a disabled BIMS score and noted the use of hypoglycemic and anticonvulsant medications. In contrast to Staff E’s practice, another RN (Staff F) reported that her responsibility for insulin administration includes checking expiration dates and ensuring vials have an open date label, and she stated she would not administer insulin from a vial without an open date. A third RN (Staff G) similarly stated that all medications, including insulin, are labeled with opening dates and that he would not administer insulin from a vial lacking an opening date. The DON also stated that all insulin vials are labeled with opening dates, which conflicted with the observed practice involving Resident #3.
Food Storage and Kitchen Sanitation Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the safe and sanitary storage, preparation, and handling of food. During an initial kitchen tour, it was found that several food items, such as chicken broth and mayonnaise, were not labeled with the date they were opened, and staff were unaware of how long these items remained safe for consumption after opening. Expired food, including turkey bacon and sliced lemons with visible spoilage, was present in the refrigerator. Additionally, there were broken eggs and visible residue and debris inside the refrigerator, including on the gaskets and shelves. The cook confirmed these findings and disposed of some spoiled items during the inspection. Further unsanitary conditions were noted throughout the kitchen and storage areas. The can opener had brown debris on the blade, spice containers had visible residue from handling with soiled gloves, and a bin containing single-serve peanut butter packets was contaminated with various debris. The dry goods storage room floor was dirty, with dried liquids and food particles under the shelves. The oven and its knobs were also found to have accumulated residue. These conditions had the potential to affect all four residents on oral diets at the time of the survey.
Failure to Notify Resident's Representative of Skin Condition
Penalty
Summary
The facility failed to notify a resident's representative regarding a significant change in the resident's skin condition. The resident, who was medically fragile and dependent on staff for care, developed a skin condition that was not communicated to the resident's mother. The mother discovered the condition during a visit and was informed by the care doctor that the resident had sores, which she had not been previously notified about. The facility's policy required prompt notification of changes in a resident's condition, but this was not adhered to in this case. The facility's documentation practices were inadequate, as there was no record of communication with the resident's representative about the skin condition. The nursing staff, including an LPN, failed to document the resident's skin condition in the progress notes or any other relevant records. The Director of Nursing (DON) acknowledged the lack of documentation and the failure to notify the resident's representative as required by the facility's policy. The report highlights that the facility did not maintain proper records or communication regarding the resident's skin condition. Despite the presence of policies for skin care management and notification of changes, these were not followed, leading to a deficiency in the facility's compliance with regulatory requirements. The lack of documentation and communication with the resident's representative was a significant oversight by the facility's staff.
Plan Of Correction
Internal and External communication is being focused upon, following our in-service for improved communication with patients, staff, providers, social services, families, parents and legal guardian/representatives. The staff will increase documentation, as evidenced by skin assessment, progress note and charting by exception. The DON will monitor for compliance with progress notes, assessments and appropriate notifications. This Plan of correction will be addressed in our QAPI Meeting scheduled for.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in meeting their needs. For two residents, there was no care plan developed for activities of daily living (ADLs), despite their dependence on staff for all ADLs. The Resident Care Manager acknowledged the inconsistency in care plan development, as some residents had ADL care plans while others did not. Additionally, the facility did not develop a care plan for a resident with a skin impairment, specifically a Deep Tissue Injury (DTI) on the left dorsal foot. Although there were active physician orders for wound care, a care plan addressing the skin impairment was not created. The Resident Care Manager confirmed the absence of a skin impairment care plan, which should have been developed. Furthermore, the facility failed to follow seizure precautions for a resident with a seizure disorder. The care plan required padding on the bed rails, but observations revealed that the rails were metal with no padding. Interviews with staff indicated a lack of awareness and availability of the necessary pads, as they were not found in the expected locations. The Director of Medical Operations was unable to access the pads, highlighting a failure in ensuring seizure precautions were in place.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to ensure the proper use of Enhanced Barrier Precautions (EBP) and hand hygiene during high-contact resident care activities. Observations revealed that staff did not consistently wear appropriate personal protective equipment (PPE), such as gowns, when providing care to residents with indwelling medical devices or those on EBP. For instance, the Activities Director was observed clipping the fingernails of a resident on Enhanced Contact Precautions without wearing a protective gown. Similarly, a respiratory therapist provided care to a resident with a tracheostomy without donning the necessary PPE. Additionally, the facility did not maintain clear and consistent signage for EBP, leading to confusion among staff about the required precautions. During the survey, it was noted that there was only one PPE isolation cart with mixed signage, causing uncertainty about which precautions to follow. Interviews with staff revealed a lack of understanding and adherence to EBP, with some staff members admitting to not wearing gowns during high-contact activities unless there was a risk of splatter. The facility also failed to practice appropriate hand hygiene during medication administration. For example, a staff member was observed administering eye drops to a resident without performing hand hygiene after removing gloves. Another staff member was seen with long, polished fingernails, which is against the facility's policy, as long nails can harbor microorganisms. These deficiencies highlight a systemic issue with infection control practices within the facility.
Failure to Promote Dignity During Feeding Assistance
Penalty
Summary
The facility failed to assist a resident with feeding in a manner that promotes dignity. Resident #17, who was admitted to the facility and assessed as rarely or never understood, was dependent on staff for all Activities of Daily Living, including eating. The resident's care plan, initiated due to dysphagia and other risk factors, included assistance with meals as needed. During an observation, Staff L was seen standing over and to the right of Resident #17 while assisting with a lunch meal, which was not in line with promoting dignity. This concern was acknowledged by the Activities Director.
Failure to Provide Adequate Fingernail Grooming for Residents
Penalty
Summary
The facility failed to provide adequate fingernail grooming for four residents who were dependent on staff for activities of daily living (ADLs). Observations revealed that these residents had long, jagged fingernails with black matter underneath, indicating a lack of proper hygiene care. The facility's policy required that personal hygiene, including nail care, be performed as needed, but this was not adhered to for the residents in question. Resident #7, who had multiple complex medical conditions and was non-verbal, was observed on two occasions with untrimmed fingernails. Staff members were unclear about who was responsible for nail care, with conflicting statements from a CNA and an RN. Similarly, Resident #12, who was also dependent on staff for ADLs, had long fingernails and redness on the palm of his hand due to the nails digging into the skin. Staff were unaware of any refusal of care by the resident, and there was no care plan addressing nail care refusal. Resident #19, who was non-verbal and dependent on staff, was observed with long, jagged fingernails. The resident's mother expressed a preference for the facility to cut his nails to prevent self-injury. Staff interviews revealed confusion about responsibility for nail care, with some stating it was the nurses' duty, while others mentioned the Activities Director. Resident #8, who was medically fragile and dependent on staff, was also found with long, untrimmed fingernails despite documentation indicating that personal hygiene care had been provided. The DON acknowledged the deficiency in maintaining proper nail care for these residents.
Deficiencies in Physician Orders and Medication Administration
Penalty
Summary
The facility failed to notify and obtain a physician order prior to providing pressure injury care for a resident with a deep tissue injury (DTI) on the left dorsal foot. The resident, who was dependent on staff for all activities of daily living, had an active physician order for wound care that expired, yet care was continued without a new order. Staff B, a registered nurse, performed wound care without a physician order, and there were no nursing notes related to the dressing change that occurred without authorization. Additionally, the facility failed to administer medications within the prescribed time frames for several residents. During an observation, it was noted that medications for multiple residents were administered late, with the medication administration record screens turning red to indicate the delay. Staff G, a registered nurse, attributed the delay to staffing issues, as there was only one nurse available for a larger number of residents than usual. The report also highlighted that a resident's tube feeding was not connected at the scheduled time, and the assigned nurse was unaware of the resident's assignment until later in the morning. This resulted in a delay in administering medications and performing necessary assessments. The Director of Nursing and the Director of Medical Operations were informed of these deficiencies, which included late medication administration and delayed assessments.
Inconsistent Administration of Enteral Nutrition
Penalty
Summary
The facility failed to ensure that the administration of enteral nutrition was consistent with the practitioner's orders for two residents. Resident #7, who has multiple complex medical conditions including cerebral palsy and feeding difficulties, was observed not receiving the prescribed amount of enteral feeding and water flushes. Over a 48-hour period, the resident received significantly less formula and water than ordered by the physician. Observations revealed issues with the feeding pump being inactive and the feeding bag not being properly labeled, indicating a lack of adherence to the prescribed feeding regimen. Similarly, Resident #15, who also has complex medical needs including tracheostomy and feeding difficulties, did not receive the prescribed amount of enteral nutrition and water flushes. Observations showed that the resident was not connected to the feeding pump at various times, and the feeding bag was not labeled with the hanging time. The feeding pump history indicated that the resident received less formula and water than ordered over a 48-hour period. Interviews with staff revealed confusion and lack of clarity regarding the resident's feeding schedule and pump operation. The Consultant Registered Dietitian confirmed the discrepancies in the administration of enteral nutrition for both residents and acknowledged the need for further education and training for the nursing staff. The facility's failure to administer enteral nutrition as per physician orders highlights a deficiency in ensuring proper nutrition and hydration for residents dependent on tube feeding.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess residents for the use of bed rails and obtain informed consent for their use for two residents. Resident #10, who was dependent on staff for activities of daily living and had multiple diagnoses including quadriplegia and seizure disorder, was not assessed for cognition and had no physician's orders or informed consent for bed rail use. The care plan for Resident #10 included the use of side rails for safety, but there was no documented assessment or consent. Similarly, Resident #130, who was also dependent on staff for all activities of daily living and had diagnoses including aphasia and seizure disorder, had a care plan that included the use of bed rails for injury prevention. However, there was no order, assessment, or signed consent for the use of bed rails. During an interview, the facility's Director of Medical Operations and Administrator acknowledged the lack of assessments and informed consent, and it was revealed that the 'Consent for Treatment' did not include the use of bed rails.
Medication Administration Errors in LTC Facility
Penalty
Summary
The report identifies a medication error rate of 14 percent, which exceeds the acceptable threshold of 5 percent. This was determined through observation, interview, and record review, where four medication errors were identified out of 28 opportunities. The errors affected a resident who was dependent on staff for all activities of daily living and had multiple diagnoses, including acute respiratory failure, tracheostomy status, diabetes insipidus, anoxic brain damage, convulsions, gastrostomy status, retinopathy, disease of the stomach and duodenum, and dependence on a ventilator. The resident's physician orders included medications such as Phenobarbital, Propranolol HCl, Simethicone, and an eye lubricant, all of which were scheduled to be administered at specific times. During a medication administration observation, a registered nurse, Staff G, was noted to be late in administering the resident's medications. The nurse acknowledged that the medication screen turns red one hour after the scheduled time, indicating a delay. The medications, including Propranolol, artificial tears, Phenobarbital, and Simethicone, were administered late, with the process starting at 9:37 AM and completing at 10:16 AM, despite being scheduled for earlier times. The Director of Nursing was informed of the multiple instances of late medication administration, highlighting a systemic issue in timely medication delivery.
Medication Management and Security Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper management of medication carts and respiratory therapy carts. On multiple occasions, medication carts were observed unlocked and unattended in common hallways, accessible to unauthorized individuals. Staff members, including a Registered Nurse and a Certified Respiratory Therapist, were responsible for these carts but failed to secure them, leaving medications such as Albuterol inhalation solution and Ventolin inhalers vulnerable to unauthorized access. The facility also neglected to remove expired biologicals from the medication room and crash cart. Expired items, including BD vacutainers and blood culture containers, were found during a review with the Director of Nursing. The responsibility for checking expiration dates was unclear, as staff members assumed it was the duty of a previous Resident Care Manager. Additionally, opened medication bottles were not properly labeled with dates, and medications requiring refrigeration were left out at inappropriate temperatures for extended periods. Improper disposal of medications was another significant issue. Staff members were observed flushing medications like Omeprazole and Gabapentin down the toilet due to a lack of proper disposal methods. Furthermore, a white round pill was discarded in a regular trash can instead of a sharps container. The facility's policy on medication storage and disposal was not consistently followed, as confirmed by interviews with the Director of Nursing and other staff members.
Deficiency in Kitchen Oversight and Meal Preparation
Penalty
Summary
The facility failed to ensure that the day-to-day kitchen operations were overseen by a qualified nutrition professional, which has the potential to affect all residents consuming food prepared in the kitchen. The facility's assessment highlighted the need for sufficient staff with appropriate competencies in food and nutrition services. However, the Food Service Manager, who was responsible for overseeing the kitchen operations, was not a Certified Dietary Manager (CDM) and had not completed the necessary courses to obtain this certification. Additionally, the Registered Dietitian (RD) was only present in the facility once a week and did not have oversight of purchasing and receiving, leaving the Operations Officer, who lacked qualifications in food service management, to supervise the kitchen. Observations during meal service revealed issues with the preparation and presentation of pureed meals for a resident, including food items pooling on the plate and not holding their shape, indicating improper consistency. The Food Service Manager and staff were unable to locate appropriately sized scoops for portioning pureed food, which was required by the approved menu. Interviews with staff confirmed the lack of proper oversight and management in the kitchen, with the Operations Officer admitting to overseeing multiple departments without specific qualifications in food service management. This lack of qualified oversight and management in the kitchen operations led to deficiencies in meal preparation and service.
Failure to Provide Properly Prepared Pureed Diet
Penalty
Summary
The facility failed to provide meals consistent with the dietary orders for a resident requiring a pureed diet. The resident, who was admitted to the facility with orders for a pureed diet with thin liquids for all meals, was observed receiving meals that did not meet these specifications. During a lunch observation, the resident was served pureed broccoli, chicken, and pasta that were not properly prepared, as they pooled on the plate and contained chunks, failing to maintain the shape of the scoop used for portioning. Similarly, during a breakfast observation, the resident received pureed cream of wheat, pancakes, and sausage, which also pooled on the plate. The Food Service Manager confirmed responsibility for these meals and acknowledged that the pureed foods were not prepared according to the recipe or the resident's dietary needs.
Inaccurate Facility Assessment in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure an accurate Facility Assessment, specifically in the area of Food and Nutrition Services. The assessment, dated June 2024, inaccurately documented the qualifications and staffing requirements for the dietitian and did not include the requirement or qualifications for a Director of Food and Nutrition Services. The Workforce Profile incorrectly listed the education level for a dietitian as a 'High School Diploma.' During an interview with the Administrator, Staff Coordinator, and Medical Operations Director, it was acknowledged that the Facility Assessment did not accurately reflect the qualifications of the dietitian or the requirement for a Director of Food and Nutrition Services.
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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 Pompano Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At The Sea - Pompano Beach | 0.4 mi | ★★★★★ | 0 | 0 |
| John Knox Village Of Pompano Beach | 2.2 mi | ★★★★★ | 0 | 0 |
| Savoy At Fort Lauderdale Rehabilitation And Nursin | 2.9 mi | ★★★★★ | 0 | 0 |
| Ft Lauderdale Health & Rehabilitation Center | 2.9 mi | ★★★★★ | 19 | 0 |
| Deerfield Beach Health And Rehabilitation Center | 3.2 mi | ★★★★★ | 1 | 0 |
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