Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 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.
Failure to assist a resident with feeding in a dignified manner. A resident with quadriplegia, trach/vent dependence, gastrostomy status, and total ADL dependence was observed being fed by CNAs who stood over the resident while the bed was elevated during meals. The DON acknowledged concerns with dignity during dining, and a CNA stated it was okay and per protocol to stand while assisting the resident with meals.
Failure to obtain informed consent for psychotropic medications for two residents. Both residents were rarely/never understood on MDS, and each had Diazepam ordered for seizure management via feeding tube. Review of the chart found no informed consent documented in the EMR, despite RN and DON statements that consent should be filed in the miscellaneous tab.
Delay in Providing Resident Personal Funds: A cognitively intact resident with quadriplegia requested a $300 check, but the funds were not provided in a timely manner. The SW told him the check would be ready the following week, yet it remained pending during later discussions and was still not received when the SW was interviewed. A grievance was filed after the Ombudsman became involved.
Advance directives and code status were not clearly documented for two sampled residents. One resident with quadriplegia, trach, ventilator dependence, and gastrostomy status had no advance directive or code status order in the EMR or paper chart, and another resident with trach, ventilator dependence, and seizures had no code status order. A third resident with obstructive hydrocephalus and a trach also had no code status order. Staff stated that if no DNR order is present, residents are presumed full code, and the SW said she discusses code status on admission but does not document the specifics.
Failure to Notify Physician and Family of Change in Condition: A resident with asthma, trach, G-tube, and ventilator dependence had multiple acute changes, including a blocked GJ tube and severe desaturation with tachycardia, leading to hospital transfers. The record did not clearly show physician notification for one event and did not document physician or family notification for another transfer, and there was no documentation of the circumstances or notifications for a later hospital send-out.
A resident admitted with G-tube status and failure to thrive did not have a baseline care plan completed within 48 hours of admission. During record review, no baseline care plan was found in the EMR, and the DON confirmed that the facility used a 7-day lookback period instead of a 48-hour baseline care plan.
A facility failed to develop person-centered care plans for advance directives or code status for multiple residents with severe neurologic and respiratory conditions, including residents who were rarely or never understood and dependent on staff for all ADLs. The facility also failed to include psychotropic medication care plans for two residents receiving diazepam and other anticonvulsant/antianxiety medications. Staff interviews showed advance directives were not routinely included in care plans or discussed in quarterly care plan meetings.
Missing and inaccurate medication administration documentation. Multiple residents with complex conditions such as epilepsy, ventilator dependence, tracheostomy status, and gastrostomy status had MAR entries left blank or lacked a documented reason when meds, treatments, vital signs, or blood sugar checks were not completed. In one observation, an LPN documented a beta-blocker as given even though it was not observed during the med pass, then later stated it had been administered late after being clicked in error.
A resident with severe dependence, contractures, and a worsening right hand wound had a soiled dressing observed on the knuckles, with no wound care care plan or interventions in the chart. The wound physician documented a DTI that progressed to a stage 3 wound and also a skin tear, but the facility had no active wound treatment orders in place until later, and staff stated wound care orders were verbally communicated rather than entered timely into the record.
A resident with quadriplegia, ventilator dependence, and total ADL dependence had a physician order for MultiPodus boots to be worn in bed on a scheduled basis, but the boots were repeatedly observed off and left at the foot of the bed during several observations. Staff gave conflicting accounts of whether therapy, nursing, or CNAs were responsible for applying the boots, and an LPN acknowledged not seeing the resident with the boots on. The resident was later observed wearing the boots, including beyond the ordered wear timeframe.
Tube feedings were not delivered as ordered for two residents who depended on enteral nutrition. One resident with malnutrition and dysphagia received less formula and water than ordered over a 72-hour period, and another resident with gastrostomy status and failure to thrive also received only about 73% of the ordered formula. Staff said the pump was repeatedly turned off for care activities such as diaper changes, meds, transfers, and bathing, with delays in restarting it.
The facility failed to obtain provider orders for suctioning and trach care for two residents with tracheostomies. One resident had diagnoses including cerebral palsy, ventilator dependence, and trach status, and the chart showed trach change and ventilator orders but no suction order. Another resident had diagnoses including obstructive hydrocephalus and trach status, and the chart showed trach change orders but no suction or trach care orders. Care plans for both residents included suctioning and trach-related interventions, while the CRT and DON stated that residents have orders for trach care and suctioning.
Failure to monitor behaviors and side effects for residents on psychotropic medications was identified for three residents. One resident with trach, vent, and seizure diagnoses had Diazepam ordered but no documented behavior or side-effect monitoring. Another resident with multiple complex diagnoses and self-injurious behaviors had Diazepam, Lamictal, and Risperidone ordered, yet the record showed no monitoring orders and an observation captured active self-hitting and pulling at trach/G-tube-related equipment. A third resident with anoxic brain injury, trach, vent, and G-tube status was receiving Valproic Acid, Levetiracetam, and Diazepam for seizures, with no documented monitoring orders; staff stated only a few residents were monitored for behaviors and side effects were not routinely tracked.
A facility failed to follow infection control protocol during trach care for a resident with ventilator dependence, trach status, and multiple serious infections when a CRT was observed handling trach ties and soiled items without PPE or hand hygiene. The facility also failed to ensure proper hand hygiene during med pass for a resident receiving meds via G-tube when an RN wore the same gloves while handling the med cart, crushing meds, opening capsules, and removing capsule casing from a med cup.
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 Assist with Feeding in a Dignified Manner
Penalty
Summary
The facility failed to assist a resident with feeding in a manner that promoted dignity. Resident #20 was admitted with quadriplegia, tracheostomy status, dependence on a ventilator, gastrostomy status, and acute and chronic respiratory failure. The resident's MDS documented bilateral impairment of the upper and lower extremities and dependence on staff for all ADLs, including eating. The care plan noted the resident required tube feeding for all nutrition and hydration needs related to dysphagia, with additional factors including quadriplegia, a feeding tube with water flushes only for patency, seizures, abnormal labs, overweight status, and being a selective eater. The care plan also included that the resident would be fed by staff and that oral intake and weight would be monitored as ordered. During observation, a CNA was seen assisting the resident with lunch while standing over and to the left of the resident, who was in bed with the head of the bed at 45 degrees. On another observation, a CNA was seen assisting the resident with breakfast while standing on the right side of the bed, which had been raised to the CNA's waist. The DON stated she had been made aware of concerns with dignity during dining and said the resident likes the bed elevated, which makes it hard for the CNA to feed him sometimes. A CNA stated that for this resident, it was okay and per protocol to stand while assisting with meals. The facility policy stated employees shall treat all residents with kindness, respect, and dignity and make every effort to assist each resident in exercising rights to assure the resident is always treated with respect, kindness, and dignity.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medication for 2 of 2 residents reviewed for unnecessary medications. Resident #13 was admitted with diagnoses including anoxic brain damage, dependence on a respirator/ventilator, tracheostomy status, and gastrostomy status. The MDS indicated the BIMS was not conducted because the resident was rarely/never understood, and the physician’s orders included Diazepam 10 mg via G-tube four times daily for seizure. Review of the resident’s electronic and paper chart found no informed consent for this medication. Resident #25 was originally admitted with diagnoses including tracheostomy status, dependence on respiratory/ventilator status, and epilepsy with recurrent seizures. The MDS documented that a BIMS was not conducted because the resident was rarely/never understood. The physician’s orders included Diazepam oral solution 5 mg/5 mL, 3 mL via J-tube three times daily, and the record contained no informed consent for psychotropic medications. During interviews, an RN stated informed consent for psychotropic medications would be filed in the miscellaneous tab of the electronic medical record, and the DON stated consent would be documented there as well, with additional consent only if the dose was increased or the medication changed.
Delay in Providing Resident Personal Funds
Penalty
Summary
The facility failed to provide a resident’s personal funds in a timely manner after receiving a request for a check. Resident #26 was admitted with quadriplegia and had a BIMS score of 15, indicating he was cognitively intact. He was able to clearly express his needs and stated during interview that he had emailed the Social Worker to request funds and had experienced long waits before receiving money in the past. He reported that he had planned to use the money but had to wait instead. Record review showed that a request for $300 was emailed to the Social Worker, who replied that the check would be ready the following week. A grievance was later filed regarding the unfulfilled request after the Regional Ombudsman’s Manager contacted the facility. Social Services progress notes documented two discussions about the requested check, including one with the resident and his first contact/caregiver, and noted that the check was still pending. The Social Worker confirmed in interview that the resident had not received the requested check and said it would hopefully be ready the next week.
Advance Directives Not Clearly Documented
Penalty
Summary
The facility failed to ensure advance directives and code status were clearly documented in the medical record for 2 of 6 sampled residents reviewed for advance directives. Facility policy stated that information about whether a resident has executed an advance directive shall be displayed prominently in the medical record and reviewed annually with the resident during the assessment process and recorded on the MDS. For Resident #20, who was admitted with diagnoses including quadriplegia, tracheostomy status, dependence on a ventilator, gastrostomy status, and acute and chronic respiratory failure, the MDS showed bilateral impairment of the upper and lower extremities and total dependence on staff for all ADLs, including eating. Review of the electronic medical record and paper chart found no documentation or physician order for advance directive or code status. For Resident #25, who was admitted and readmitted with diagnoses including tracheostomy status, dependence on respiratory ventilator status, and epilepsy with recurrent seizures, the MDS documented that a Brief Interview of Mental Status was not conducted because the resident was rarely or never understood. Review of the physician's orders found no order addressing code status. Review of Resident #28, admitted with diagnoses including obstructive hydrocephalus, tracheostomy status, and presence of a cerebrospinal fluid drainage device, also found no physician order addressing code status. During interviews, an RN stated there should be an order in the chart and that if there is no order the resident is presumed full code; she acknowledged there was no code status order for Residents #25 and #28. The SW stated she discusses code status on admission but does not document the specifics, and the DON stated only DNR requires an order and that without one the resident is presumed full code.
Failure to Notify Physician and Family of Resident Change in Condition
Penalty
Summary
The facility failed to inform the physician and family of changes in condition for Resident #7, who had a complex medical history including asthma, preterm newborn gestational age, respiratory failure of newborn, gastrostomy status, tracheostomy status, and dependence on respiratory ventilator support. The resident was admitted to the facility and was sent to the hospital three times between 03/10/26 and 03/30/26. The facility policy required prompt notification of the resident, attending physician, and representative when there was a change in medical or mental condition, including notification within 24 hours except in emergencies. On 03/10/26, nursing documentation showed the resident’s GJ tube J-port was obstructed, the feeding pump alarmed, flushing met high resistance, and no formula or gastric contents returned. The DON was notified, the resident’s mother was made aware, and an order was received to send the resident to the hospital, but it was not clear whether the physician was notified or whether the transfer order came from the physician or the DON. On 03/17/26, the resident had desaturation to 62% with tachycardia while on ventilator support; respiratory therapy intervened, the DON was notified, and the resident was transferred by emergency services, but the record did not document that the physician or family was notified of the change in condition. On 03/30/26, there were no nurse’s notes or change-in-condition assessment documenting the circumstances of the hospital transfer or whether the physician or family was notified.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan for Resident #2 within the first 48 hours of admission. Resident #2 was admitted with diagnoses including Gastrostomy Status and Failure to Thrive. Record review of the electronic medical record on 04/16/26 found no baseline care plan for the resident, despite the expectation that one should have been completed within 48 hours of admission. During an interview on 04/16/26, the DON was unable to produce a baseline care plan and stated she would contact the remotely working MDS coordinator. The DON later reported that the MDS coordinator said the facility used a 7-day lookback period and that this was what they used for the baseline care plan, and the DON confirmed there was no 48-hour baseline care plan for Resident #2.
Missing Care Plans for Advance Directives and Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for advance directives or code status for 6 of 6 sampled residents reviewed for advance directives. Residents #2, #4, #7, #20, #25, and #28 all had records showing no care plan for advance directives or code status. Several of these residents had complex medical conditions and were unable to participate in a Brief Interview for Mental Status because they were rarely or never understood, including residents with diagnoses such as congenital hydrocephalus, cerebral palsy, obstructive hydrocephalus, quadriplegia, tracheostomy status, ventilator dependence, and gastrostomy status. Resident #20 was admitted with quadriplegia, tracheostomy status, ventilator dependence, gastrostomy status, and acute and chronic respiratory failure. The MDS showed bilateral impairment of the upper and lower extremities and total dependence on staff for all ADLs, including eating. The electronic medical record contained no advance directive formulation and no physician order for code status, and the care plan for advance directives was not developed. Similar record review findings were documented for Residents #2, #4, #7, and #28, with no care plan for advance directives or code status found in their records. The facility also failed to develop and implement a comprehensive person-centered care plan for psychotropic medications for 2 of 28 sampled residents receiving psychotropic medications. Resident #13 had orders for anticonvulsant and antianxiety medications, including valproic acid, levetiracetam, and diazepam, and Resident #25 had an order for diazepam oral solution. Despite these medication orders, the active and resolved care plans for Resident #13 did not include a psychotropic medication care plan, and the care plan for Resident #25 also lacked a psychotropic medication care plan. During interviews, the Social Worker stated advance directives were not included in care plans and were not discussed in quarterly care plan meetings, and the DON stated she would not expect to see a care plan unless there was an order for DNR.
Missing and inaccurate medication administration documentation
Penalty
Summary
The facility failed to document medication administration or document why medications were not administered for multiple residents. The report states that the facility policy required medications to be charted immediately after administration and, if a medication was not given, the licensed staff were to initial the eMAR and document the reason. Interviews with staff and review of records showed that this documentation was not consistently completed for several residents. For one resident with congenital hydrocephalus, epilepsy, failure to thrive, and a G-tube, the MAR showed missing documentation for clonazepam on one day and for clonazepam, cyproheptadine, lansoprazole, levetiracetam, and sodium chloride on another day. The progress notes contained no documentation for those dates. For another resident with obstructive hydrocephalus, tracheostomy status, and a cerebrospinal fluid drainage device, the MAR showed multiple medications and treatments without initials or a documented reason they were not given, including ferrous sulfate, MiraLax, senna, cetirizine, gabapentin, hydroxyzine, metronidazole, Neocate, Calmoseptine, Peptamen Jr., and sucralfate. The progress notes did not document why those medications were not administered. Staff interviews confirmed that when medications are not given, the MAR should be coded and the reason documented in progress notes. For a resident with congenital heart malformation, chromosomal abnormality, ventilator dependence, gastrostomy status, epilepsy, and tracheostomy status, the MAR showed a missed vital signs entry and an empty medication slot for diazepam, with no progress note explaining why the medication was not administered or why vital signs were not monitored. For another resident with epilepsy, recurrent seizures, diabetes, COPD, ventilator dependence, and tracheostomy status, the MAR showed multiple missed or undocumented medications and care items, including clonazepam, Lantus, levetiracetam, omeprazole, baclofen, diazepam, chlorhexidine oral care, insulin lispro, and a missed blood sugar check, with no corresponding explanation in the progress notes. During a separate medication administration observation for a resident with anoxic brain damage, ventilator dependence, tracheostomy status, gastrostomy status, and pre-excitation syndrome, the nurse documented metoprolol as given even though it was not observed during the surveyor’s observation; the nurse later stated she had clicked the medication by mistake and then administered it later, acknowledging it was given late.
Delayed Wound Care Orders and Incomplete Documentation
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not implemented for a resident with severe functional dependence and multiple diagnoses including anoxic brain damage, ventilator dependence, tracheostomy status, and gastrostomy status. The resident was dependent on staff for all ADLs and had contractures of the upper extremities, with the right hand contracted inward and the knuckles resting on the bed sheets. During the initial tour, the resident’s right hand knuckles were covered with a soiled dressing that was not dated or initialed. The electronic chart did not contain a care plan or interventions for pressure wound injuries. The wound physician documented a wound on the right second finger/knuckle area that progressed from an unstageable DTI with intact skin to a stage 3 wound, and later also documented a skin tear on the right hand. The physician’s reports included treatment plans for skin prep, then alginate calcium with gauze island border dressing, and later continuation of treatment, with the plan discussed with nursing staff. However, the physician’s orders in the chart showed an active wound order beginning 04/14/26, and there were no other wound care treatments in place before 04/13/26. During interviews, an LPN stated she was not sure when wound care was scheduled and did not usually do wound care for the resident, an RN stated the DON usually entered physician orders, and the DON acknowledged that wound care orders had been verbally communicated but there was no order in place prior to 04/14/26.
Failure to Apply Ordered Orthotic Boots
Penalty
Summary
The facility failed to follow physician's orders in a timely manner for application of bilateral orthotic boots for a resident with quadriplegia, tracheostomy status, ventilator dependence, gastrostomy status, and acute and chronic respiratory failure. The resident's MDS showed bilateral impairment of the upper and lower extremities and total dependence on staff for all ADLs. A physician's order dated 03/19/26 directed that MultiPodus boots be worn in bed for 8 hours on and 4 hours off continuously for 24 hours to address foot drop, plantar flexion contractures, and heel pressure ulcers. During multiple observations on 04/13/26, 04/14/26, and 04/15/26, the resident was seen in bed without the orthotic boots on, and the boots were observed at the foot of the bed. On 04/16/26, the resident was first observed wearing the boots, and later remained wearing them beyond the 8-hour timeframe. Staff interviews reflected conflicting understanding of responsibility for applying the boots: a CNA stated therapy put them on and took them off, a PT stated CNAs were responsible after daily care and nursing was responsible to ensure they were worn, an RN stated therapy could apply them, and an LPN stated nursing was responsible and acknowledged not seeing the resident with the boots on the prior day. The DON was informed of the concern.
Tube Feedings Not Delivered as Ordered
Penalty
Summary
The facility failed to provide enteral feedings per physician orders for two residents who depended on tube feeding for nutrition and hydration. One resident had diagnoses including unspecified protein calorie malnutrition, gastritis, and an artificial opening of the gastrointestinal tract, and his care plan stated that he relied on tube feeding for all nutrition and hydration needs due to dysphagia. His physician ordered a specific Pediasure 1.0 mixture via jejunum tube at 77 mL per hour continuously for 24 hours, with a 24-hour total of 1680 mL of formula plus 180 mL of water. When the pump history was reviewed, the resident had received 4164 mL over 72 hours, compared with the ordered 5580 mL, meaning he received 74.6% of the ordered volume and was short 1416 mL over 3 days. The second resident had diagnoses including gastrostomy status and failure to thrive. Physician orders directed Nutren formula at 45 mL per hour continuously via jejunum tube, along with water flushes of 45 mL every 6 hours, but the orders did not include total daily volumes. Pump history showed 2364 mL of formula and 360 mL of water flushes over 72 hours, and the resident received 72.9% of the ordered formula. Staff stated the pump was turned off during diaper changes, medication administration, transfers, bathing, and other care activities, and that there could be delays in restarting it because CNAs could not restart the pump.
Missing Orders for Tracheostomy and Suctioning Care
Penalty
Summary
The facility failed to obtain provider orders for respiratory care, including suctioning and trach care, for 2 of 2 residents reviewed for respiratory services. For Resident #4, the record showed diagnoses including cerebral palsy, dependence on respirator status, tracheostomy status, cleft palate, apnea of newborns, and myotonic muscular dystrophy. Physician orders included monthly and PRN trach changes, ventilator settings, and gauze under the tracheotomy cuff/flange to prevent skin irritation and breakdown, but there was no order for suction. The care plan for this resident included the intervention to suction as necessary. For Resident #28, the record showed diagnoses including obstructive hydrocephalus, tracheostomy status, presence of a cerebrospinal fluid drainage device, and unspecified lack of expected normal physiological development in childhood. The physician orders included monthly and PRN trach changes, but there was no order for suction or trach care. The care plan included changing suction canisters and accessories, normal saline lavage and suction as needed for airway clearance, and tracheostomy care with vitamin A&D ointment twice daily and as needed to maintain skin integrity. During interviews, the CRT stated each resident has orders for trach care and suctioning, and the DON stated trach care was performed every shift and documented on the RMAR, and that each resident has orders for trach care.
Failure to Monitor Behaviors and Side Effects for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to monitor behaviors and side effects for residents receiving psychotropic medications for 3 of 28 sampled residents. The deficiency involved Resident #25, Resident #5, and Resident #13, all of whom had significant medical histories and were receiving medications including psychotropic agents. Record review, observations, and staff interviews showed that the facility did not have documented monitoring of behaviors or side effects for these residents despite their medication regimens and care plan needs. Resident #25 was admitted with diagnoses including tracheostomy status, dependence on ventilator status, and epilepsy with recurrent seizures. The resident had an order for Diazepam oral solution via J-tube three times daily, but review of the April 2026 MAR, TAR, and progress notes showed no monitoring of behaviors or side effects. During interviews, an RN stated monitoring would be documented on the MAR, TAR, or in progress notes, while the consultant pharmacist acknowledged that no behavior monitoring was being documented for this resident. The DON stated behaviors and side effects would only be documented if they were not the resident’s normal behaviors. Resident #5 had diagnoses including congenital heart malformation, chromosomal abnormality, dependence on ventilator status, gastrostomy status, epilepsy, and tracheostomy status. The resident’s care plans addressed self-injurious behaviors such as pulling out the G-tube extension, pulling out the tracheostomy, and hitting or biting himself, and also addressed use of drugs with altering effects on the mind with interventions to evaluate effectiveness and side effects and monitor mood and behavior. Physician orders included Diazepam, Lamictal, and Risperidone for irritability associated with autism, but the record showed no orders for monitoring behaviors or side effects. During observation, Resident #5 was seen pulling on tracheostomy ties and hitting himself on the abdominal binder covering the G-tube. Resident #13 had diagnoses including anoxic brain damage, dependence on ventilator status, tracheostomy status, and gastrostomy status. The resident was receiving Valproic Acid, Levetiracetam, and Diazepam via G-tube for seizures, and the MAR and physician orders contained no monitoring orders for behaviors or side effects. During multiple observations, Resident #13 was seen with eyes closed and appearing to be sleeping. Staff interviews indicated that one RN did not have anyone assigned who required behavior or side-effect monitoring, and an LPN stated there was a binder on the medication cart for behavior monitoring, only two residents were monitored for behaviors, and side effects were not monitored unless a change in behavior was noticed.
Infection Control Lapses During Tracheostomy Care and Medication Dispensing
Penalty
Summary
The facility failed to follow infection control protocol during tracheostomy care for a resident who was admitted with diagnoses including anoxic brain damage, dependence on a ventilator, tracheostomy status, gastrostomy status, sepsis due to Serratia, lobar pneumonia, and pulmonary mycobacterial infection. The resident’s MDS assessment showed dependence on staff for all ADLs. During an afternoon tour, a CRT was observed in the resident’s room tying the tracheostomy strings without wearing gloves or a gown, while soiled dressings, trach strings, and a pink plastic tray were sitting on the foot of the bed on top of the bed linen without a barrier. The observation continued as the CRT went to get clean gloves and, without performing hand hygiene, put them on. He then collected the soiled items from the foot of the bed, discarded them, removed the gloves, and again did not perform hand hygiene before donning another pair of clean gloves. He returned to the bedside and placed a towel on the left side of the resident’s face before removing the covers to view the resident’s hands. During interviews, another CRT stated that PPE is required during trach care, especially suctioning, and the CRT involved acknowledged that he was not wearing gloves and stated he was not sure what happened that day. The facility also failed to ensure appropriate hand hygiene during medication dispensing for another resident who received all medications via G-tube and had diagnoses including sepsis, bronchitis, Lafora progressive myoclonus epilepsy with status epilepticus, convulsions, dependence on a ventilator, tracheostomy status, gastrostomy status, and bacteremia. During medication administration observation, an RN wearing gloves dispensed multiple medications while touching the medication cart drawers, bingo cards, computer mouse, and pill crusher. She then opened Zonisamide capsules while still wearing the same gloves, dumped the contents into a medication cup, and picked a capsule casing out of the cup without removing the gloves or performing hand hygiene. The RN stated she wore gloves because the medications needed to be crushed and opened, and the DON later acknowledged that it is not protocol for the nurse to wear gloves while dispensing medications unless the medication requires being touched such as opening a capsule.
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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Illustrative
What surveyors actually found near you
We read the 292 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.