Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Ft Lauderdale Health & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain and document required testing of emergency battery backup lighting in accordance with NFPA 101. During record review with the Maintenance Director, no documentation was available for the monthly 30-second tests or the annual 90-minute tests for all sampled battery backup emergency lights. The Maintenance Director acknowledged the absence of these records, and the deficiency was determined to affect all residents and staff.
Surveyors found that the facility failed to maintain its Essential Electrical System (EES) in accordance with NFPA 99 and related standards when record review showed that conductance testing was not performed for 2 of 2 sealed generator batteries over a defined period, and only one generator battery was tested during that time. During an interview, the Maintenance Director acknowledged that required testing had not been completed for both batteries. This lapse in required emergency power system maintenance affected the facility’s single EES and all residents and staff relying on it.
Surveyors found that staff assigned to the designated smoking patio did not have the necessary knowledge to operate the electronic magnetic locked exit gate leading to the public way. During a fire safety tour, a CNA serving as the Smoking Area Attendant repeatedly entered the correct access code but could not open the gate because she pulled instead of pushed, demonstrating that staff were not fully able to utilize this means of egress as required by NFPA 101. The Administrator and Maintenance Director confirmed these observations, and the deficiency was noted as affecting residents who smoke.
Surveyors found that a medication refrigerator in the South Wing medication room was plugged into a receptacle that was not distinctly marked or supplied from the critical branch of the essential electrical system, as required by NFPA 99. This issue was identified for 1 of 5 sampled medication refrigerators and affected residents whose medications were stored in that unit. The Administrator and Maintenance Director observed and acknowledged the noncompliant receptacle configuration during the fire safety tour, and the findings were later reviewed with them along with photographic evidence.
Inaccurate Psychiatric Diagnosis Assessment: A resident with a history of schizoaffective disorder, bipolar type, major depressive disorder, and bipolar disorder was not accurately assessed for psychiatric diagnosis during PASARR/MDS review. The MDS Coordinator said the diagnoses entered in PCC came from a psych note rather than the hospital record, while the DON acknowledged the difference between schizoaffective disorder, bipolar type and separate schizoaffective/bipolar diagnoses. The Psychiatric NP said he had requested an audit of the bipolar and MDD diagnoses, and a later note stated bipolar disorder was discontinued due to insufficient clinical evidence.
A resident with DM2, dementia, CKD, and severe cognitive impairment had a sliding-scale insulin order requiring the MD to be called when blood glucose was above 400 mg/dL. On three occasions, the resident’s blood sugar was documented at 471, 407, and 411 mg/dL, but there was no documentation that the physician was notified or that follow-up nursing interventions were recorded. Staff and the DON acknowledged the missing documentation and failure to follow the order.
Unsafe Smoking Assessment: A resident with severe cognitive impairment was not accurately assessed for smoking safety. During observation, the resident was hunched forward in a wheelchair with her cigarette held below table level near her lap, ash fell to the ground, and a hole was seen in her pant leg that the resident said came from smoking. The ADON admitted the resident would not be considered a safe smoker under those conditions and had not noticed the clothing damage when completing the smoking evaluation.
Improper Foley Catheter and Peri-Care Technique: A resident with an indwelling urinary catheter, diabetes, and moderate cognitive impairment received Foley catheter care and peri-care in an unsanitary manner. A CNA and another staff member used the same gloves throughout the procedure and reused basin water after cleaning the buttock area, then returned to the catheter tubing area without changing gloves; multiple nursing leaders acknowledged the cross-contamination.
A resident was receiving O2 via NC without a current physician order for the therapy, and staff acknowledged the missing order. Another resident with COPD had an MDS that did not code O2 therapy, even though the resident had an O2 order and was observed with the concentrator set at 4 L/min instead of the ordered 2 L/min. Nursing staff and the MDS coordinator acknowledged the discrepancies.
Controlled medication records were not accurately reconciled for three residents. One resident with neurologic and diabetic conditions had a scheduled Tramadol dose documented on the MAR but not on the control record, another resident with a femur fracture and moderate cognitive impairment had mismatched PRN Tramadol documentation between the MAR and control record, and a third resident with chronic pain diagnoses had discontinued Oxycodone left in the medication cart and later removed without corresponding nursing documentation or provider renewal.
A resident with intact cognition had three OTC topical creams left unsecured at the bedside, including one expired tube that was not promptly discarded. A South wing med cart was also found unlocked and unattended, and topical meds in a second-floor med storage room were improperly labeled with only numbers on the boxes. The DON, an LPN, and an RN/UM acknowledged the issues.
Failure to follow the approved lunch menu portion. A kitchen observation found that pork plated for residents on regular texture diets was served as thinly sliced, bone-in pork chop portions instead of the approved 3-ounce Pork Chop BBQ serving. When weighed, the portion measured 2.5 oz including the inedible bone, and the FSD acknowledged the finding.
Mechanical Soft Diet Not Served in Appropriate Form: A resident with severe cognitive impairment, dementia, malnutrition, GERD, and complaints of pain when swallowing was ordered a mechanical soft diet, but was observed served a hot dog cut into large chunks. The FSD and SLP both acknowledged the food was not appropriate for the resident’s ordered diet.
Infection control practices were not followed during blood glucose monitoring and IV antibiotic administration. An RN performed a fingerstick on a cognitively intact resident with diabetes without hand hygiene, then stored the glucometer without disinfecting it between uses. In a separate event, an RN administered IV vancomycin to a resident with bacteremia and other serious diagnoses while wearing an untied gown, handling dropped IV supplies, and continuing the procedure with contaminated items and inconsistent glove and connector handling.
Surveyors found that the facility failed to provide a safe, clean, and comfortable environment in several rooms and common areas, with issues such as missing toilet tissue, dirty floors, food crumbs, flies on a resident's bed, broken soap dispensers, inaccessible toilet paper, damaged furniture, stained carpeting, lifted shower tiles, and a clogged sink. These deficiencies were acknowledged by the ADON during a facility tour.
The facility failed to follow the approved menu and portion sizes for 137 residents, serving Breaded Popcorn Shrimp instead of plain shrimp, and insufficient portions of Salisbury Steak. The shrimp provided only 15 grams of protein per 4-ounce portion, requiring an 8-ounce serving to meet the 4-ounce protein requirement. The Salisbury Steak was also under-portioned, providing only 19 grams of protein instead of the required 28 grams.
The facility failed to complete MDS Resident Comprehensive Assessments on time for six residents with various diagnoses, including dementia and Alzheimer's. The assessments were delayed by three to four weeks due to the Social Services Director not completing her sections on time. The MDS Coordinator and DON acknowledged the need for timely completion to ensure accurate resident evaluation and care planning.
Two residents in the facility did not receive timely podiatry care, resulting in elongated toenails. One resident, with multiple diagnoses including dementia, had not seen a podiatrist since February, and her care plan did not address foot care refusal. Another resident, with no cognitive impairment but dependent on staff for daily activities, had not seen a podiatrist since admission three months prior. Both residents were not listed for podiatry services, and staff interviews revealed a lack of documentation and communication regarding their foot care needs.
A resident with Celiac Disease in an LTC facility was not provided with a sufficient variety of gluten-free products, despite being on a therapeutic gluten-free modified diet. The resident, who had no cognitive impairment and was dependent on staff for most ADLs, expressed frustration over receiving only gluten-free bread and having to order food from outside. Interviews revealed that the facility's ordering list did not include gluten-free flour or pasta, limiting options. Despite meetings with the resident, the facility failed to adequately address his dietary preferences, leading to his reliance on external food sources.
The facility failed to adhere to food safety standards, affecting 123 residents. Observations revealed improper thawing of ground beef, inadequate dishwashing machine maintenance, and unsafe food temperatures. Additional issues included mold on a vent, rust on equipment, and improper storage of cleaning cloths and waste, posing contamination risks.
Failure to Maintain and Document Required Emergency Battery Backup Lighting Tests
Penalty
Summary
The deficiency involves the facility’s failure to maintain and document required testing of emergency battery backup lighting in accordance with NFPA 101 standards. During a record review conducted with the Maintenance Director, surveyors requested documentation for the required monthly 30-second functional tests and the annual 90-minute tests of the facility’s battery backup emergency lights. For all 3 of 3 sampled battery backup emergency lights, no documentation was provided to show that the monthly 30-second tests had been performed. Similarly, no documentation was available to demonstrate that the required annual 90-minute battery backup lighting tests had been conducted for the same 3 of 3 emergency lights. The Maintenance Director, interviewed concurrently with the record review, acknowledged the lack of documentation. The deficiency was determined to affect all residents and staff in the facility and was discussed with the Administrator and the Maintenance Director during the exit conference.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K291 Emergency Lighting It is the practice of this facility to maintain emergency battery backup lighting. Immediate Corrective Action: The Maintenance Director was in-serviced on the required monthly and annual testing for emergency battery backup lighting. The 3 of 3 emergency battery backup lights were tested. Identification of other residents potentially affected: All residents have the potential to be affected by this practice. Measures: Maintenance Director and/or designee will in-service the Maintenance Assistants on the required monthly and annual testing for emergency battery backup lighting. Monitoring: Maintenance Director will complete monthly audits for three months, to ensure that the monthly test is being completed. Results of these audits will be reviewed by the QA committee during monthly meetings to ensure continued compliance. K0291 The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K291 Emergency Lighting It is the practice of this facility to maintain emergency battery backup lighting. Immediate Corrective Action: The Maintenance Director was in-serviced on the required monthly and annual testing for emergency battery backup lighting. The 3 of 3 emergency battery backup lights were tested. Identification of other residents potentially affected: All residents have the potential to be affected by this practice. Measures: Maintenance Director and/or designee will in-service the Maintenance Assistants on the required monthly and annual testing for emergency battery backup lighting. Monitoring: Maintenance Director will complete monthly audits for three months, to ensure that the monthly test is being completed. Results of these audits will be reviewed by the QA committee during monthly meetings to ensure continued compliance.
Failure to Perform Required Generator Battery Conductance Testing for Essential Electrical System
Penalty
Summary
The deficiency involves the facility’s failure to maintain the Essential Electrical System (EES) in accordance with NFPA 99 and related NFPA standards for its emergency power system. During a record review conducted with the Maintenance Director at 12:15 PM on the survey date, surveyors found that generator battery conductance testing was not performed for 2 of 2 sealed generator batteries over a specified period. The records showed that, during that same period, only one generator battery was conductance tested, leaving the second sealed battery untested. These findings applied to the facility’s single EES and therefore affected all residents and staff. The Maintenance Director, during the concurrent interview, acknowledged that the conductance testing had not been completed as required for both sealed batteries. The surveyors cited noncompliance with multiple NFPA 99, NFPA 101, and NFPA 110 provisions, which require proper maintenance and testing of emergency power sources, including generator batteries, to ensure the EES functions as intended. The findings were formally reviewed with the Administrator and the Maintenance Director at the exit conference, confirming that the lapse in required conductance testing constituted a failure to meet the applicable life safety and licensure requirements for the EES.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K918 Electrical Systems - Essential Electric Systems It is the practice of this facility to maintain the Essential Electrical System (EES). Immediate Corrective Action: The Maintenance Director was in-services on completing monthly generator battery conductance testing on both batteries. The Generator Monthly Load Test was completed on both batteries on [R]. Identification of other residents potentially affected: All residents have the potential to be affected by this practice. Measures: Maintenance Director and/or designee will in-service the Maintenance Assistants on completing monthly generator battery conductance testing on both batteries. Monitoring: Maintenance Director and/or designee will do random monthly audits of the Generator battery conductance testing to ensure compliance, for 3 months. Results of these audits will be reviewed by the QA committee during monthly meetings to ensure continued compliance. K0918 The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K918 Electrical Systems - Essential Electric Systems It is the practice of this facility to maintain the Essential Electrical System (EES). Immediate Corrective Action: The Maintenance Director was in-services on completing monthly generator battery conductance testing on both batteries. The Generator Monthly Load Test was completed on both batteries on [R] . Identification of other residents potentially affected: All residents have the potential to be affected by this practice. Measures: Maintenance Director and/or designee will in-service the Maintenance Assistants on completing monthly generator battery conductance testing on both batteries. Monitoring: Maintenance Director and/or designee will do random monthly audits of the Generator battery conductance testing to ensure compliance, for 3 months. Results of these audits will be reviewed by the QA committee during monthly meetings to ensure continued compliance.
Staff Inability to Operate Locked Smoking Patio Exit Gate
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff assigned to the designated smoking patio had the necessary knowledge and ability to operate the electronic magnetic locked gate used as a means of egress. During a fire safety tour with the Administrator and Maintenance Director at the smoking patio, the Smoking Area Attendant, a CNA, was asked to unlock the exit gate that leads to the public way. She entered the access code several times but was unable to open the gate. The Maintenance Director confirmed that she was using the correct code. It was further observed that the Smoking Area Attendant was pulling on the gate instead of pushing it, which prevented the gate from opening despite the correct code being entered. This demonstrated that not all staff knew how to evacuate through the electronically locked gate or had the key or knowledge necessary to utilize this means of egress in accordance with NFPA 101 requirements. The Administrator and Maintenance Director acknowledged these findings during the tour and at the exit conference. This deficiency affects residents who use the designated smoking area.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K211 Means of Egress - General: It is the practice of this facility to ensure that all staff have the key, access code or knowledge, necessary to utilize the means of egress. Immediate Corrective Action: The Smoking Patio C.N.A. was educated that after entering the code or using the key at the gate, the door needs to be pushed to open. Identification of other residents potentially affected: All residents have the potential to be affected by this practice. Measures: Maintenance Director and/or designee will in-service the CNAs assigned to the smoking patio regarding the code and/or key to the egress gate. Maintenance Director and/or designee will in-service the nurses, that in the event of emergency, the key to the Smoking Patio Gate is on each nurses station key ring. A key to the Smoking Patio egress gate will be added to the all nursing station key ring and the Smoking Patio key ring. Monitoring: Maintenance and/or designee will complete random audits weekly for four weeks of the Smoking Patio to validate that the CNAs have the code and/or key to the Smoking Patio egress gate, and then monthly for 3 months. Results of these audits will be reviewed by the QA committee during monthly meetings to ensure continued compliance. The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K211 Means of Egress - General: It is the practice of this facility to ensure that all staff have the key, access code or knowledge, necessary to utilize the means of egress. Immediate Corrective Action: The Smoking Patio C.N.A. was educated that after entering the code or using the key at the gate, the door needs to be pushed to open. Identification of other residents potentially affected: All residents have the potential to be affected by this practice. Measures: Maintenance Director and/or designee will in-service the CNAs assigned to the smoking patio regarding the code and/or key to the egress gate. Maintenance Director and/or designee will in-service the nurses, that in the event of emergency, the key to the Smoking Patio Gate is on each nurses station key ring. A key to the Smoking Patio egress gate will be added to the all nursing station key ring and the Smoking Patio key ring. Monitoring: Maintenance and/or designee will complete random audits weekly for four weeks of the Smoking Patio to validate that the CNAs have the code and/or key to the Smoking Patio egress gate, and then monthly for 3 months. Results of these audits will be reviewed by the QA committee during monthly meetings to ensure continued compliance.
Medication Refrigerator Not Connected to Critical Branch Receptacle
Penalty
Summary
Surveyors identified a deficiency involving the electrical supply to a medication refrigerator in the South Wing medication room. During a fire safety tour conducted with the Administrator and the Maintenance Director at 4:00 PM, it was observed that the South Wing medication room refrigerator was not plugged into a distinctly marked receptacle that was supplied from the critical branch of the essential electrical system, as required by NFPA 99. The receptacle serving this refrigerator lacked the distinctive color or marking that indicates connection to the life safety or critical branch. This issue was noted for 1 of 5 sampled medication refrigerators and was determined to affect residents residing in the South Wing, whose medications are stored in that refrigerator. The Administrator and the Maintenance Director were interviewed at the time of observation and acknowledged the findings. The deficiency and supporting photographic evidence were reviewed again with them during the exit conference at 5:30 PM. No additional resident-specific clinical details or medical histories were provided in the report.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K917 Electrical Systems - Essential Electric System It is the practice of this facility to ensure the critical branch supplied power to select receptacles serving medication refrigerator. Immediate Corrective Action: The Maintenance Director was in-services regarding all refrigerators that store medicine in the medication room need to be plugged into a critical branch supplied power receptacle, identified by red cover. The Maintenance Director contacted the vendor to ensure the critical branch supplied power was properly identified. Identification of other residents potentially affected: All residents have the potential to be affected by this practice. Measures: Maintenance Director and/or designee will in-service the Maintenance Assistants regarding the facilities practice ensuring that critical branch supplied power to select receptacles serving medication refrigerator are properly identified by a red cover. Maintenance Director and/or designee will complete a House-wide audit of all the medication room to ensure that the medication refrigerator are plugged into the correct receptacle. Monitoring: Maintenance Director will random monthly audits of the refrigerators in the medication room to ensure that it is plugged into the red cover receptacle. Results of these audits will be reviewed by the QA committee during monthly meetings to ensure continued compliance. The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. K917 Electrical Systems - Essential Electric System It is the practice of this facility to ensure the critical branch supplied power to select receptacles serving medication refrigerator. Immediate Corrective Action: The Maintenance Director was in-services regarding all refrigerators that store medicine in the medication room need to be plugged into a critical branch supplied power receptacle, identified by red cover. The Maintenance Director contacted the vendor to ensure the critical branch supplied power was properly identified. Identification of other residents potentially affected: All residents have the potential to be affected by this practice. Measures: Maintenance Director and/or designee will in-service the Maintenance Assistants regarding the facilities practice ensuring that critical branch supplied power to select receptacles serving medication refrigerators are properly identified by a red cover. Maintenance Director and/or designee will complete a House-wide audit of all the medication room to ensure that the medication refrigerator are plugged into the correct receptacle. Monitoring: Maintenance Director will random monthly audits of the refrigerators in the medication room to ensure that it is plugged into the red cover receptacle. Results of these audits will be reviewed by the QA committee during monthly meetings to ensure continued compliance.
Inaccurate Psychiatric Diagnosis Assessment
Penalty
Summary
The facility failed to accurately assess a resident for psychiatric diagnosis for 1 of 2 sampled residents reviewed for PASARR. Resident #15 was admitted and readmitted with diagnoses including schizoaffective disorder, bipolar type, and major depressive disorder, recurrent, moderate. The quarterly MDS showed a BIMS score of 15, indicating no cognitive impairment. Record review also showed prior diagnoses of bipolar disorder, schizoaffective disorder, bipolar type, and major depressive disorder, recurrent, moderate, while the resident’s hospital discharge paperwork did not document a psychiatric diagnosis on the PASARR reviewed from the hospital. During interviews, the Director of Social Services stated that admissions are reviewed through PASARR and hospital documentation, with corrections made if needed. The MDS Coordinator stated that the psychiatric diagnoses entered into PCC came from a psychiatric note written by the Psychiatric Nurse Practitioner rather than the hospital record. The Psychiatric Nurse Practitioner stated he had asked for an audit of the bipolar disorder and major depressive disorder diagnoses for about 6 months and said the only sustainable diagnosis was schizoaffective disorder, bipolar type. The DON stated the facility was not aware of that audit request and acknowledged that schizoaffective disorder, bipolar type is different from schizoaffective disorder and bipolar disorder as separate diagnoses. A progress note entered after surveyor intervention stated that bipolar disorder was discontinued due to insufficient clinical evidence supporting manic or hypomanic episodes.
Failure to Notify Physician and Document Interventions for Elevated Blood Sugar
Penalty
Summary
The facility failed to follow a physician’s order and failed to document nursing interventions for a resident’s elevated blood sugar levels. The resident had diagnoses including Diabetes Mellitus type II, encephalopathy, dementia, hypertensive heart and chronic kidney disease stage 4, unspecified convulsions, and major depressive disorder, and had a BIMS score of 00 indicating severe cognitive impairment. The physician’s order for Novolin R FlexPen sliding scale insulin directed staff to give 10 units and call the MD when blood glucose was greater than 400 mg/dL. Record review showed three occasions in February 2026 when the resident’s blood sugar was documented as 471 mg/dL, 407 mg/dL, and 411 mg/dL. On those occasions, Staff G documented the insulin administration on the MAR, but there was no notation in the MAR or nurses’ notes showing that the physician was notified as ordered. There was also no documented physician response in the record. The resident’s diabetes care plan directed staff to monitor blood sugar as ordered, administer coverage insulin as ordered and needed, notify the physician if problems occurred, and observe for signs and symptoms of hyperglycemia and hypoglycemia. During interviews, Staff B, Staff F, the ADON, Staff A, and Staff G acknowledged that the resident had three episodes of blood sugar greater than 400 mg/dL without documentation that the physician had been notified as ordered. Staff B and Staff F stated that the nurse should have documented follow-up or a re-check of the blood sugar to determine effectiveness and to support contacting the physician for a clear directive. The DON also acknowledged that the physician’s order should have been followed and that the nurse should have notified the physician and documented the intervention in the resident’s record.
Unsafe Smoking Assessment
Penalty
Summary
The facility failed to accurately assess a resident with severe cognitive impairment for safe smoking. The resident’s quarterly MDS documented a BIMS score of 5/15, and the resident had last been evaluated as a safe smoker on 01/01/26. The facility’s smoking evaluation included criteria such as remaining alert, not forgetting the cigarette, not allowing ashes or lit material to fall, and not endangering self or others while smoking. During observation on the smoking patio, the resident was seen hunched forward in a wheelchair with her head down and her hands below the tabletop, with her face not clearly visible and her hands not visible to the surveyor. Staff stated the resident always sits in that position and that she checks to make sure the resident is not sleeping before offering a cigarette. The staff member lit the cigarette for the resident, who then held it near her left leg below the table, allowed it to burn while answering questions, and had ash fall to the ground. The surveyor observed a hole in the resident’s left pant leg near the knee, and the resident stated the hole was from her cigarette and that she leaves a trail of holes in her clothes. The ADON, who completed the smoking evaluation, admitted that a resident smoking while leaning over below table level with hands near the lap would not be a safe smoker and stated she had not noticed the holes or burn marks on the resident’s clothing.
Improper Foley Catheter and Peri-Care Technique
Penalty
Summary
The facility failed to ensure Foley catheter care and peri-care were performed in a sanitary manner for one sampled resident. Resident #10 had diagnoses including metabolic encephalopathy, sepsis, diabetes mellitus type II, obstructive and reflux uropathy, and hypertensive heart disease, and had an indwelling urinary catheter to bedside drainage bag ordered for obstructive uropathy. The resident also had a BIMS score of 9, indicating moderate cognitive impairment. The facility’s policy stated that catheter care was intended to prevent catheter-associated urinary tract infections and included washing the genitalia and perineum, using clean gloves, and cleansing the catheter from the insertion site outward. During observation of Foley catheter and peri-care, Staff L and Staff M performed the procedure while the resident was in bed. After washing the resident’s buttock area, Staff L returned to clean the Foley catheter tubing area again without changing gloves and used the same basin water that had already been used for the buttock area. Staff L was observed wearing the same pair of gloves throughout the entire peri-care and Foley catheter care procedure, from front to back and back to front. Staff L, Staff M, an LPN, an RN/UM, the RN/ADON/Nurse Supervisor, and the DON all acknowledged that the gloves and basin water should have been changed during the procedure to avoid cross-contamination.
Failure to Follow Oxygen Orders and Accurately Code Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not following oxygen orders and by not ensuring the MDS assessment was accurate. One resident with COPD, respiratory failure, pulmonary fibrosis, pneumonia, hypertension, hemiplegia, and encephalopathy was observed receiving oxygen via nasal cannula at 2 liters, but the record showed no current physician’s order for oxygen therapy administration with parameters. The resident stated she wore oxygen most of the day and continuously at night due to shortness of breath. Nurses’ notes documented oxygen as actively infusing, and staff acknowledged during interview that the resident was receiving oxygen without a current physician’s order in place. The DON acknowledged that a physician’s order should have been obtained for the oxygen administration therapy. A second resident with Type 2 diabetes mellitus and COPD had a quarterly MDS assessment that did not code oxygen therapy in Section O, despite a physician’s order for an oxygen concentrator with humidifier at 2 liters per minute via nasal cannula to keep oxygen saturation above 92%. The care plan documented alteration in breathing pattern related to COPD and included oxygen-related interventions. During observations, the resident was seen in bed with oxygen in place and functioning, but the concentrator was set at 4 liters per minute rather than the ordered 2 liters. Staff later acknowledged that the oxygen saturation readings recorded for the resident were not correct and that the concentrator setting did not match the order. Interviews with nursing staff and the MDS coordinator confirmed the discrepancies. Staff stated that nurses were responsible for setting the concentrator according to the medical order and for recording oxygen saturation, and the MDS coordinator acknowledged that residents on oxygen therapy should be coded in Section O. The record review and observations showed that the resident was receiving oxygen at a higher flow rate than ordered, while the MDS assessment did not reflect oxygen therapy as required.
Controlled Medication Reconciliation and Discontinued Medication Removal Errors
Penalty
Summary
The facility failed to accurately reconcile controlled medications and failed to ensure discontinued controlled medications were removed from the medication cart for three residents reviewed for controlled medication reconciliation. Review of the facility policy on controlled substances stated that the facility must comply with requirements related to handling, storage, disposal, and documentation of controlled substances, and that an individual resident controlled-substance record must be maintained for each resident receiving a controlled substance. For one resident with hemiplegia and hemiparesis following cerebrovascular disease, type 2 diabetes mellitus, and mononeuropathy, Tramadol 50 mg was documented on the MAR as given, but the Medication Monitoring/Control Record did not show a nurse signature or administration entry for one scheduled dose. For a second resident with a right femur fracture and moderate cognitive impairment, Tramadol PRN administrations were documented on the MAR, but the Medication Monitoring/Control Record contained different entries, including a dose not documented on the MAR and a crossed-out date and time. For a third resident with polyneuropathy, type 2 diabetes mellitus, gout, joint pain, and low back pain, Oxycodone 5 mg was discontinued, yet a tablet was later removed from the locked medication cart drawer and there was no nursing progress note showing administration to the resident or communication with the medical provider for renewal. The DON acknowledged discrepancies between the Medication Monitoring/Control Record and the MARs.
Unsecured and Improperly Labeled Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in a safe and secure manner when three OTC topical cream medications were left unsecured at the bedside of Resident #138. Resident #138 was admitted and re-admitted with diagnoses including pneumonia, COPD with acute exacerbation, respiratory failure, pulmonary fibrosis, hypertension, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and encephalopathy. Her BIMS score indicated intact cognition, and during observation she stated the creams were used primarily for her hands and other dry skin areas. During the room observations, the resident had three tubes of topical medication left unattended on her nightstand and overbed table, including Salonpas with Lidocaine Plus 4% with an expiration date of 02/2027, Maximum Strength Blue Emu with 4% Lidocaine with an expiration date of 01/2020, and an anti-itch cream containing pramoxine hydrochlorozide 1% and menthol 0.5% with an expiration date of 02/2027. The same unsecured medications were observed again later in the day and the following morning. Staff J, an LPN, acknowledged the medications should not have been left there and that the expired topical cream should have been promptly discarded. The facility also failed to keep a medication cart on the South wing locked and secure when it was observed unlocked and unattended, with no nursing staff in sight, while containing medications for 30 residents. In addition, a second-floor medication storage room contained topical medications in plastic bags with only numbers written on the boxes, including one box marked with a room number that did not exist on that floor. Staff F, the unit manager, stated topical medications were stored in the room and that she and evening nurses were responsible for keeping the storage room current and properly maintained. The DON and RN/ADON/Nurse Supervisor acknowledged the unsecured bedside medications, the expired topical medication, and that medication carts must always be kept locked and secure.
Failure to Follow Approved Lunch Menu Portion
Penalty
Summary
The facility failed to follow the approved lunch menu for residents receiving regular texture foods. The approved March 11, 2026 lunch menu specified a 3-ounce serving of Pork Chop BBQ, but during a kitchen observation with the Food Service Director present, the pork plated for service was observed to be thinly sliced, bone-in pork chop portions. When the surveyor requested that a portion be weighed, the plated pork measured 2.5 ounces including the inedible bone. The Food Service Director acknowledged the finding during the observation.
Mechanical Soft Diet Not Served in Appropriate Form
Penalty
Summary
The facility failed to serve food in the appropriate form to meet the needs of Resident #72, who had an order for a mechanical soft diet. Resident #72 was admitted to the facility and, on the most recent complete assessment, had a BIMS score of 07 indicating severe cognitive impairment. The resident’s diagnoses included non-Alzheimer’s dementia, malnutrition, chronic lung disease, and GERD, and the assessment documented complaints of pain when swallowing during the 7-day look-back period. The resident’s diet orders included regular diet, mechanical soft texture, and thin consistency, and the care plan identified the resident as at risk for altered nutrition and/or hydration related to the mechanically altered diet, dementia, CAD, GERD, COPD, protein/calorie malnutrition, low BMI, and muscle wasting/atrophy. During lunch observation in the dining area, Resident #72 was served a hot dog cut into large chunks. When the Food Service Director was shown photographic evidence, the FSD acknowledged the concern and demonstrated that the hot dog as served was not appropriate for a resident with a mechanical soft diet order, noting that a fork could not be pushed completely through the skin of the hot dog. The Speech Language Pathologist later also acknowledged that the hot dog served to the resident was not appropriate based on the photographic evidence and the FSD’s demonstration.
Infection Control Failures During Glucose Monitoring and IV Antibiotic Administration
Penalty
Summary
The facility failed to clean and disinfect a glucometer according to manufacturer instructions and failed to perform hand hygiene during blood glucose monitoring for a resident with Type 2 diabetes mellitus and COPD who was cognitively intact with a BIMS score of 14. During an Accu-Chek observation, the RN prepared the glucometer and supplies, entered the resident’s room wearing gloves without performing hand hygiene, used the bed remote while still gloved, and completed the blood glucose check. After discarding her gloves, she exited the room without washing her hands, placed the glucometer and sharps cup on top of the medication cart, and only used hand sanitizer after being questioned by the surveyor. She then stored the glucometer in the medication cart drawer without disinfecting it. The RN stated she had worked at the facility for one month and said she would clean the glucometer after checking a few more residents’ blood glucose levels. She later removed glucometers from the drawer and placed them on top of the medication cart, stating she did not have wipes in the cart to clean them. The facility policy required reusable blood glucose meters to be cleaned and disinfected between resident uses and required gloves to be removed and hands washed after the procedure. The facility also failed to implement infection control practices during IV antibiotic administration for a resident with cerebral infarction, bacteremia, and pneumonitis due to inhalation of food and vomit, who had a BIMS score of 08. During IV medication administration, the RN entered the room wearing a gown that was untied and dragging on the hallway floor and gloves. She dropped the IV tubing and IV medication bag on the floor, discarded the tubing, picked up the bag without wiping it down, and later returned holding the dirty IV medication bag and tubing with gloved hands. She continued the procedure, touched the IV tubing and connector, used alcohol wipes on the tubing clave and the resident’s IV connector, and then reached for another alcohol wipe while still handling the IV connection.
Failure to Maintain a Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe, clean, comfortable, and homelike environment in 9 out of 100 rooms and elevator areas. Specific findings included rooms without toilet tissue, dirty floors with dark gray spots, food crumbs on the floor, and scuffed or peeling paint on bathroom doors. In one room, multiple flies were present on a resident's bed and furniture, and the resident expressed a desire for the flies to be removed. Additional observations included a broken and unreachable soap dispenser, wardrobe drawers that could not fully close with a handle positioned incorrectly, and toilet paper rolls placed in locations that were not easily accessible. Further deficiencies were noted in common areas, such as elevator carpeting and the carpeting in front of elevators on the first and third floors, which were dirty and stained. In one room, bathroom shower tiles were lifted from the wall, and a side light cover was incorrectly positioned. Another room had a clogged bathroom sink. These findings were acknowledged by the Assistant Director of Nursing during a facility tour.
Failure to Adhere to Approved Menu and Portion Sizes
Penalty
Summary
The deficiency identified in the report pertains to the failure of the facility to adhere to the approved menu and portion sizes for 137 out of 145 residents who consume meals orally. On the date in question, the facility's lunch menu specified various shrimp-based entrees for different dietary needs, including Regular, Mechanical Soft, Pureed, Consistent Carbohydrate, and No Added Salt diets, all requiring 4 ounces of shrimp. However, during the lunch tray line observation, it was noted that Breaded Popcorn Shrimp was served instead of the specified plain non-breaded shrimp. The Certified Dietary Manager (CDM) explained that the substitution was due to the non-delivery of the plain shrimp. Upon weighing, the Breaded Popcorn Shrimp portion was found to be 4.5 ounces, but it only provided 15 grams of protein, necessitating an 8-ounce portion to meet the 4-ounce protein requirement. Additionally, the Salisbury Steak, an alternate entree for the Renal Diet, was also found to be deficient in portion size. The steak was recorded at 2.5 ounces, providing only 19 grams of protein, whereas a 5-ounce portion was needed to deliver the required 4-ounce protein serving. The facility had purchased insufficiently sized steak patties, which contributed to the deficiency. These findings were confirmed with the facility's Administrator, highlighting a significant deviation from the approved menu and portion sizes, impacting the nutritional needs of the residents.
Delayed MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) Resident Comprehensive Assessments in a timely manner for six residents. These residents were admitted or readmitted with various diagnoses, including osteoarthritis, hypertension, dementia, chronic obstructive pulmonary disease, Alzheimer's disease, and others. The assessments were not completed within the required timeframes, with delays ranging from three to four weeks past the Assessment Reference Date (ARD). The facility's policy requires that MDS assessments be conducted and submitted according to federal and state guidelines. However, the MDS Coordinator, Staff D, did not electronically sign the assessments until several weeks after the due dates. The delay was attributed to the Social Services Director not completing the Resident Social Work Assessment sections on time, which was acknowledged by both Staff D and Staff E during interviews. The Director of Nursing (DON) confirmed that the assessments should have been completed in a timely manner by all departments. The Social Services Director was unable to provide a specific reason for the delay in completing her sections of the assessments. This lack of timely completion of assessments could impact the accurate and timely evaluation of residents, which is necessary for developing appropriate care plans.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to provide timely podiatry care for two residents, leading to elongated toenails and potential discomfort. Resident #4, who has multiple diagnoses including dementia and peripheral vascular disease, was admitted to the facility with a care plan that did not address foot care refusal. Despite being dependent on staff for daily activities, Resident #4 had not received podiatry care since February 2024, and her toenails were observed to be elongated. Staff interviews revealed a lack of documentation regarding her refusal of toenail care, and she was not listed in the podiatry consult log. Similarly, Resident #130, who has a range of medical conditions including pneumonia and pressure ulcers, had not seen a podiatrist since his admission three months prior. His MDS assessment indicated no cognitive impairment, yet he was dependent on staff for most activities of daily living. Observations confirmed that his toenails were elongated, and there was no written podiatry consult in his clinical record. Staff interviews indicated that Resident #130 was not on the list to be seen by the podiatrist, despite the podiatrist visiting the facility twice a week. The deficiency was identified through observations, interviews, and record reviews, highlighting a systemic issue in ensuring residents receive necessary podiatry care. Both residents were not appropriately logged for podiatry services, and there was a lack of communication and documentation regarding their foot care needs. The facility's process for scheduling podiatry visits was inadequate, resulting in missed care for these residents.
Failure to Provide Adequate Gluten-Free Diet for Resident with Celiac Disease
Penalty
Summary
The facility failed to provide a variety of gluten-free products for a resident with Celiac Disease, who was on a therapeutic gluten-free modified diet. The resident, who had no cognitive impairment and was dependent on staff for most activities of daily living, expressed frustration over the limited gluten-free options available, stating that he was only receiving gluten-free bread and had to order food from outside to meet his dietary needs. Despite promises made during care plan meetings with the resident and his family, the facility did not have a sufficient variety of gluten-free products, such as pasta or flour, available for the resident. Interviews with the facility's Registered Dietitian (RD) and the Food Service Supervisor (FSS) revealed that the facility's ordering list did not include gluten-free flour or pasta, limiting the options available to the resident. The RD acknowledged the resident's history of extreme weight loss and the need for a gluten-free diet due to Celiac Disease. However, the RD and FSS confirmed that only gluten-free bread was available, and the resident's preferences for other gluten-free products had not been adequately addressed, leading to the resident's reliance on ordering food from outside the facility. The RD and FSS had met with the resident to discuss his dietary preferences, but the facility's documentation did not reflect any updates or changes to the resident's preferences. The RD admitted that the facility could have done a better job accommodating the resident's dietary needs and acknowledged that the resident had complained about the limited gluten-free options. Despite weekly interactions with the resident, the FSS did not document these visits, and the resident continued to express concerns about the lack of gluten-free options, leading to his decision to order meals from outside the facility.
Deficiencies in Food Safety and Equipment Maintenance
Penalty
Summary
The facility was found to have multiple deficiencies in food storage, preparation, and service, affecting 123 of the 145 residents who consume food orally. During an initial kitchen observation, it was noted that ground beef was being thawed in water that was too warm, exceeding the regulatory requirement of 70 degrees Fahrenheit. Additionally, the dishwashing machine had a significant build-up of decayed food matter and lime, and the exhaust hood had peeling paint, both of which posed contamination risks. The facility also failed to store cleaning cloths properly and left garbage and trash uncovered. In a subsequent observation, food temperatures on the tray assembly line were not maintained at safe levels, with fried eggs and orange juice being served at temperatures far below the regulatory standards. The dishwashing machine was not operating at the required temperature due to staff oversight, and a soiled ladder was improperly stored in a clean area. Furthermore, a vent over the 3-compartment sink was covered in mold, and rust was found on food storage racks and the legs of a convection oven. These observations indicate a failure to adhere to professional standards for food service safety, potentially compromising the health and safety of the residents. The issues identified include improper thawing and temperature control of food, inadequate cleaning and maintenance of kitchen equipment, and improper storage of cleaning materials and waste, all of which could lead to food contamination.
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fort Lauderdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Savoy At Fort Lauderdale Rehabilitation And Nursin | 0.1 mi | ★★★★★ | 0 | 0 |
| Pearl At Fort Lauderdale Rehabilitation And Nursin | 2.1 mi | ★★★★★ | 0 | 0 |
| Wilton Manors Healthcare & Rehabilitation Center | 2.6 mi | ★★★★★ | 0 | 0 |
| John Knox Village Of Pompano Beach | 2.8 mi | ★★★★★ | 0 | 0 |
| Childrens Comprehensive Care Center Inc | 2.9 mi | ★★★★★ | 2 | 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 July 2026) and official state health department websites.