Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Nspire Healthcare Lauderhill during CMS and state inspections, most recent first.
Failure to follow the approved menu and recipe was identified during lunch service. Residents were served baked chicken instead of the posted and approved barbecue chicken, and the FSD stated the kitchen lacked barbecue sauce and the menu had not been changed. Residents were also served a small bone-in chicken thigh portion, and the FSD stated the kitchen did not have a scale to verify proper portion sizes.
Food Storage and Sanitation Deficiencies in Kitchen: The kitchen failed to store, prepare, distribute, and serve food according to professional standards. A cook was observed with visible facial hair and no beard net, expired milk and gelatin were found in storage and on the tray line, ice and melting buildup were present in the freezer, and the ice machine had orange-colored growth with condensation dripping into the ice. The can opener had food residue, sanitizer was below the required level, and cleaning cloths were used improperly during tray line service, including wiping a plate before it was sent to dietary staff.
Facility maintenance and housekeeping services were not provided consistently to keep resident rooms clean and sanitary. Surveyors observed dust on AC filters, peeling and damaged paint, worn furniture surfaces, damaged door frames and windowsills, and missing AC filters in multiple rooms. A resident with dementia and moderate cognitive impairment also had a bathroom with no toilet seat and a cracked, lifted floor, and staff had not reported the issue to maintenance.
The facility failed to develop or follow care plans for multiple residents: two residents involved in a resident-to-resident altercation had wandering and behavior issues without care plans, a resident with asthma and COPD had no respiratory care plan, a resident receiving psychotropic meds had no medication-related care plan, and a resident at risk for falls did not have the call light kept within reach as planned. Staff interviews and record review showed repeated wandering into rooms, an altercation with physical contact, respiratory diagnoses and inhaler orders without corresponding care planning, psychotropic orders without a care plan, and the call light repeatedly found on the floor instead of accessible to the resident.
Failure to provide activities to meet a resident's needs. A resident with severe cognitive impairment, total ADL dependence, and tube feedings was observed in bed on multiple occasions with no music, TV, or interaction. The Activities Dir said the resident was not on 1:1 in-room activities, and the activity log documented participation in cards/games, music, TV, socialization, and drinking coffee even though the resident had an order for no PO intake.
The facility failed to follow standards for inhaler and PEG tube medication administration, including improper inhaler technique, lack of monitoring, and failure to verify PEG placement while enhanced barrier precautions were in place. The facility also did not obtain a dermatology consult for a resident with severe cognitive impairment and ongoing skin rash/scratching, and it failed to coordinate hospice documentation for two residents after changes in condition were noted.
Failure to provide ordered protein supplements for a resident with a stage 2 sacral pressure ulcer. The resident had dementia, DM2, protein-calorie malnutrition, and severe cognitive impairment. The Clinical Dietitian and MD ordered liquid protein three times daily, but MAR review showed it was not given, and an RN later verified the order was not in the MAR.
Failure to arrange ENT consultation: A resident with hemiplegia, dysphagia, and depressive disorder, and a BIMS score indicating cognitive intactness, complained of ear ringing and popping, prompting an ENT consult order. Social services delayed the referral process, an outside appointment could not be accommodated due to stretcher transport limitations, and after the spouse later agreed to proceed, no new ENT appointment was made.
A resident with severe cognitive impairment and psychotic-related diagnoses received Geodon oral and IM for agitation even though the physician later stated the IM and oral orders were intended to last only 14 days. Records showed the resident continued to receive IM doses for aggression and destructive behavior, with no baseline EKG or labs before the medication was started. Staff gave conflicting accounts about whether the order was still active and whether it had been verified by the physician, and the PASSAR documentation was not updated despite new aggressive behaviors.
Improper Refuse Disposal and Accumulated Debris: Surveyors observed debris outside the main dumpster, including gloves, paper, plastic, lids, a paint roller, and a paint can, after a Cook said the area had been swept a few days earlier. In another refuse area, pallets, discarded furniture, and other unidentifiable debris were piled near the dumpster, and a later observation showed the piles had increased. The Maintenance Director acknowledged the buildup and said refuse was picked up by two companies on different schedules.
Staff failed to follow CDC standard precautions and EBP during resident care and meal service. A nurse placed glucometer supplies on a resident’s meal table without disinfecting it, discarded used paper towels on the table, and a CNA later placed the meal tray there without encouraging hand hygiene. Another resident was served lunch without hand sanitation despite recent toileting-related behaviors, and an RN administering PEG tube meds wore gloves but not a gown as required by EBP.
A resident with complex medical needs received IV antibiotics and IV line flushing from an LPN who did not have the required IV therapy certification or training. Staff interviews confirmed that LPNs were performing IV-related tasks without proper certification, and the facility was unable to provide documentation verifying the LPN's qualifications, despite facility policy and professional standards requiring such certification.
The facility failed to treat residents with dignity during dining, leaving several waiting for meals while others ate. Additionally, a resident with severe cognitive impairment did not receive necessary assistance with eating, despite requiring substantial maximum assistance. Observations showed untouched meal trays, indicating a lack of staff support.
The facility failed to ensure that bathroom emergency call lights were accessible for residents and staff in a secure unit. Observations over three days revealed that emergency cords were tied, wrapped, or missing in the bathrooms of several residents with various medical conditions, including dementia and cognitive impairments. Despite staff acknowledgment of the issue, some bathrooms remained non-compliant until surveyor intervention.
A resident with PTSD and on anticoagulant medication did not have appropriate care plans in place. The resident, with moderate cognitive impairment, was admitted with multiple diagnoses including PTSD and was prescribed Eliquis for A-fib. Despite physician's orders to monitor for bleeding, the facility lacked care plans for both PTSD and anticoagulant use, as confirmed by the MDS Coordinator.
A resident with severe cognitive impairment did not receive necessary vision services due to the facility's failure to arrange an eye doctor appointment, despite a family member's request. The Social Service Director initially believed the appointment had been made but later confirmed it had not, resulting in the resident not receiving the needed care.
Two residents with severe cognitive impairment experienced significant weight loss due to the facility's failure to provide timely nutritional interventions. Despite low meal intake and fluctuating appetites, the Clinical Dietitian and Registered Dietician delayed addressing the weight loss. Observations revealed inadequate assistance during meals, contributing to ongoing nutritional deficiencies.
A resident with a history of Hemiplegia and Chronic Kidney Disease experienced significant weight loss due to the facility's failure to follow physician's orders for tube feeding. Observations showed discrepancies in the administered formula amount, and staff reported a malfunctioning pump. The resident's behavior of pulling out the feeding tube was mentioned but not documented.
A facility failed to assess and provide psychosocial services for a resident with PTSD. The resident, a veteran, was not screened for PTSD upon admission, and staff were unaware of his triggers. The MDS Coordinator did not create a care plan, and the resident was not seen by a psychiatrist until a month later. The facility's PTSD policy was not followed, leading to a delay in addressing the resident's needs.
A facility failed to provide necessary psychosocial services for a resident with PTSD. The resident, a veteran, was admitted with PTSD but was not screened or provided with an individualized care plan as required by the facility's policy. The Social Service Director was unaware of her responsibilities regarding PTSD care, and the facility lacked a PTSD screening tool, leading to inadequate care for the resident's condition.
The facility failed to maintain accurate records for controlled medications for two residents. One resident's Tramadol administration was not documented in the MAR despite being given, and another resident's Oxycodone was signed out without date or time documentation. Staff acknowledged the oversight, citing distractions as a reason for incomplete records.
The facility failed to provide the correct diet consistency for two residents on a mechanical soft diet. Observations revealed that residents were served cooked red cabbage in pieces too large and tough for the diet's requirements, leading to one resident coughing. The Speech Language Pathologist confirmed the inconsistency and discussed it with the dietary team.
The facility failed to maintain food safety and hygiene standards in the Main Kitchen. Issues included flying insects near an open dumpster, disconnected drainage treatment, and improper temperature control in refrigeration units. Additionally, food storage practices were inadequate, with unlabeled and opened packages found. An Activity Coordinator was observed not washing hands after touching personal items before feeding a resident.
The facility failed to accurately document high-risk medication use in MDS assessments for two residents. One resident was incorrectly noted as taking an anticoagulant instead of an antiplatelet, while another was mistakenly documented as receiving an anticoagulant due to confusion with Procrit injections. The MDS Coordinator acknowledged the errors, attributing them to being overwhelmed and confused about medication classifications.
Failure to Follow Approved Menu and Recipe
Penalty
Summary
The facility failed to follow the approved menu for lunch on 02/16/26 and failed to follow the approved recipe for lunch on 02/18/26. During lunch service in the dining room, the posted menu outside the Dining Room and the approved menu both documented Barbecue Chicken, but residents were served a piece of chicken thigh that did not appear to be barbecued chicken. When asked about the substitution, the Food Service Director stated the kitchen did not have barbecue sauce and had prepared baked chicken instead, and said the posted menu should have been changed the night before. During the same meal observation, residents were served a single bone-in chicken thigh that appeared to be a small portion, and when asked about the weight of the bone-in chicken thighs, the Food Service Director stated the facility did not have a scale in the kitchen to ensure proper portion sizes were served.
Food Storage and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. During a kitchen tour, a cook was observed with visible facial hair but no beard hair net. The dry storage area had accumulated debris on the floor next to a reach-in freezer. In the walk-in refrigerator, 22 cartons of low-fat milk were found with an expiration date of 02/06/25, and additional cartons of low-fat milk on the tray line had expiration dates of 02/06/25 and 02/13/25. Two single servings of strawberry gelatin were also found in the walk-in refrigerator with an expiration date of 02/10/26. The walk-in freezer had ice accumulation on the pipes under the cooling unit, ice on a box of commercially processed omelets, icicles on the shelf under the cooling unit, and a large amount of ice at the left corner entrance and around the door jamb, frame, and door. Ice from the top of the door jamb was melting onto the floor below. In a large reach-in freezer, an unrecognizable yellow-colored spillage was observed on the bottom where two large tubs of ice cream were sitting, and one tub had an open tear. The ice machine had orange-colored growth and condensation dripping into the ice, the ice scoop holder was placed on top of the machine where it could not dry properly with nesting water observed, the can opener had food residue and debris, and the quaternary ammonia sanitizer in a food assembly area was below the 200 parts per million required to sanitize food and nonfood contact surfaces. During a second observation, multi-surface cleaning cloths were used to wipe the steam table while food was being plated, were not placed in a sanitizing bucket after use, and one cloth was used to wipe the top of a plate where food had dripped over the side before the plate was passed to dietary staff.
Failure to Maintain Clean and Safe Resident Rooms and Bathroom Fixtures
Penalty
Summary
The facility failed to provide maintenance and housekeeping services to maintain a clean and sanitary environment in 10 of 58 rooms. Survey observations documented dust accumulation on wall-mounted air conditioning unit filters, peeling or damaged paint on walls and door frames, worn and damaged bed foot boards, worn overbed tables with particle board exposed, damaged windowsills, and missing filters in one air conditioning unit. These conditions were observed in multiple resident rooms during the survey, and the Director of Maintenance was made aware of the concerns during an environmental tour and acknowledged the findings. Resident #28 was readmitted to the facility with diagnoses including dementia, anxiety, restlessness and agitation, and psychosis. The annual MDS dated 11/24/24 indicated a BIMS score of 11, showing moderate cognitive impairment, and that the resident was independent with ambulation and toilet transfer. During repeated observations, the resident’s bathroom had no toilet seat and the floor on the left side of the toilet was cracked and lifted. Staff L, a Restorative CNA, acknowledged the toilet and floor issues and stated the resident used the bathroom independently and did not have incontinence issues, but she had not alerted maintenance to the missing toilet seat or damaged floor. Review of the grievance and maintenance logs did not show any complaint or work order request for the toilet seat replacement, and the Maintenance Director stated the issue was not on the log.
Failure to Develop and Follow Care Plans for Behavior, Respiratory Needs, Psychotropic Medications, and Falls
Penalty
Summary
The facility failed to initiate care plans for wandering and behavioral problems for two residents involved in a resident-to-resident altercation. One resident had diagnoses of dementia, anxiety disorder, and depressive disorder, and the MDS showed memory problems, moderately impaired cognition, wandering, and elopement risk. The other resident had diagnoses including hemiplegia, dysphagia, and depressive disorder, and reported that the first resident entered his room, tried to grab his phone, and slapped him on the face. Facility documentation also recorded that the first resident entered the second resident’s room yelling and screaming and struck him on both arms, with no injuries noted. Staff interviews described the resident as frequently walking the halls, entering other residents’ rooms, needing redirection, and at times being affectionate or aggressive, but the care plan did not include wandering or behavior interventions before the altercation. The facility also failed to include a care plan for a resident with asthma and COPD. That resident was admitted with diagnoses including asthma, COPD, dementia, mood disturbance, anxiety, and cognitive communication deficit, and the admission MDS showed severe cognitive impairment. Physician orders included Budesonide-Formoterol inhalation aerosol for asthma, and psychiatry notes documented poor insight, judgment, and memory. Although nursing notes described no acute breathing distress at admission, the care plan did not include goals, plans, or interventions for asthma or COPD, while it did include behavior-related plans for other diagnoses. The facility further failed to develop and implement a care plan for psychotropic medication use for a resident with multiple psychiatric and medical diagnoses, including dementia and psychotic disorder with hallucinations. The resident’s orders included fluvoxamine, quetiapine, bupropion, and divalproex, but the record contained no care plan for psychotropic medications. Staff interviews showed uncertainty about who was responsible for care planning, and the DON acknowledged that no psychotropic medication care plan was in place. In addition, the facility did not follow fall interventions for a resident with multiple diagnoses including schizoaffective disorder, heart failure, diabetes, anxiety, schizophrenia, difficulty walking, and vertigo. The resident’s care plan stated the call light should be within reach and the resident should be encouraged to use it, but repeated observations found the call light on the floor wedged under the roommate’s bed frame, and staff acknowledged the call light was not positioned as planned.
Failure to Provide Activities for a Cognitively Impaired Resident
Penalty
Summary
Provide activities to meet all resident's needs. Based on observation, interview, and record review, the facility failed to provide activities to meet the interests of and support the physical, mental, and psychosocial well-being of 1 of 2 sampled residents for activities (Resident #98). Resident #98 was admitted to the facility with severe cognitive impairment, was dependent for activities of daily living, and was receiving tube feedings. A physician order dated 11/04/25 indicated the resident was not to take anything by mouth, including food or drink. Observations of Resident #98 on multiple dates and times showed the resident in bed with no music, TV, or other entertainment or interaction. The Activities Director stated the resident was not on 1:1 in-room activities, although there had been discussion about making her 1:1 after her return from the hospital because she was receiving tube feedings. The Activities Assistant provided documentation showing daily participation in cards/games, music/singing, verbal socialization, TV/movies, and drinking coffee from 02/01/26 through 02/18/26, but the Activities Director confirmed the resident could not drink coffee because she was not allowed anything by mouth and stated the resident had not attended activities.
Medication Administration, Dermatology Consult, and Hospice Coordination Failures
Penalty
Summary
The facility failed to follow professional standards of practice for oral inhalation medication administration for a resident with COPD, asthma, and severe cognitive impairment. During observation, the RN administered albuterol HFA by spraying one puff into the resident’s mouth without asking the resident to inhale, then gave a second puff in the same manner. The RN did not ask the resident to rinse his mouth, did not monitor for reactions after the medication was given, did not obtain vital signs, and did not perform a respiratory assessment before leaving the room. The facility also failed to follow its enteral tube medication administration procedure for a resident with a PEG tube, dysphagia, and severe cognitive impairment. During observation, the RN administered oral medications by mouth, then prepared to give medications via the PEG tube. She washed her hands and donned gloves, but did not don a gown despite enhanced barrier precautions being posted at the door. She inserted a syringe into the PEG tube end port and poured water into the syringe for flush, but did not verify tube placement, did not check residual, and did not listen for bowel sounds. When only about 10 ml of Jevity had entered, she disconnected the syringe and stopped the feeding, then discarded the feeding supplies. The facility failed to obtain a dermatology consult in a timely manner for a resident with severe cognitive impairment, chronic xerosis, and scratching behavior. The resident was observed scratching his arms and legs, with patchy areas and scratch marks noted on the legs. An order for a dermatology consult had been entered after the resident was noted with a generalized skin rash, but the record contained no evidence that dermatology was consulted. The facility also failed to coordinate care with hospice for two residents receiving hospice services. For one resident, a hematoma to the forehead was documented after the resident was unable to explain what happened, and the physician and family were notified, but the record contained no hospice MD or nurse documentation related to the incident. For another resident, edema and tightness of the right arm were observed and hospice was notified, but the record contained no orders, assessment, or documentation regarding the arm condition. The DON stated there should be a hospice binder for residents on hospice, but no hospice book was found for either resident.
Failure to Provide Ordered Protein Supplement for Resident With Pressure Ulcer
Penalty
Summary
The facility failed to provide ordered protein supplements to Resident #25, who was readmitted with diagnoses of dementia, type 2 diabetes, and unspecified protein-calorie malnutrition and had a BIMS score of 06 indicating severe cognitive impairment. The resident was observed eating breakfast and consumed about 70% of the meal. The skin check progress notes documented a stage 2 pressure ulcer, partial thickness, on the sacrum on 01/12/2026, 01/19/2026, 01/26/2026, 02/02/2026, and 02/09/2026. The care plan noted a history of actual pressure area and risk for further skin impairment due to decreased mobility and incontinence. The Clinical Dietitian’s progress note on 01/23/2026 directed an increase in liquid protein supplement, and the physician’s order on the same date documented ProSource liquid protein three times a day. Review of the MAR for January and February 2026 showed that no protein supplements were provided as ordered. The DON stated that when a wound is identified as a pressure wound, the wound care report is to be sent to the Clinical Dietitian and Administrator, and the Clinical Dietitian stated she would review wound reports and order protein supplements if needed. Staff P later verified that Resident #25 was not receiving the protein supplements and that the order was not in the MAR.
Failure to Arrange ENT Consultation
Penalty
Summary
The facility failed to provide medically related social services to help a resident achieve the highest practicable physical, mental, and psychosocial well-being. Resident #10 was admitted with diagnoses of hemiplegia, dysphagia, and depressive disorder, and the quarterly MDS showed a BIMS score of 14, indicating cognitive intactness. In late November, the resident complained of ringing in the left ear and popping in the right ear, and the Nurse Practitioner ordered an ENT consultation. The resident’s wife was informed of the consultation order. The ENT referral was not completed in a timely manner. Social services documented that the resident’s face sheet and order were sent to the in-house ENT specialist about three weeks after the order was written, and later documented that the POA and resident no longer wanted to proceed with the audiology consultation at that time. During interviews, the resident stated he had been waiting months to see an ENT specialist and continued to experience ringing in his ears. The spouse stated she initially declined the appointment because she believed the visit would have to be paid out of pocket, later clarified the issue with social services, and was told the in-house ENT had already left and the resident would be seen on the next visit. Social services also stated that an outside ENT appointment had been scheduled but could not be accommodated because the transport provider did not have a stretcher, and after the spouse later said she wanted to proceed, no new ENT appointment was made.
Unverified Antipsychotic Order Remained Active
Penalty
Summary
The facility failed to ensure an antipsychotic medication order remained active and was verified by the physician for a resident with severe cognitive impairment and multiple psychiatric-related diagnoses. Resident #51 was admitted with diagnoses including cognitive communication deficit, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety, and the most recent MDS showed severe cognitive impairment. Records also showed no diagnosis of schizophrenia or bipolar disorder, while the PASSAR Level I documentation identified psychotic disorder, delirium, and altered mental status. Review of the medication record showed that Resident #51 was started on Geodon oral 40 mg every 12 hours and Geodon IM 20 mg every 12 hours as needed for agitation related to psychotic disorder with hallucinations due to known physiological condition. The physician later stated that the oral and IM Geodon had been intended to be valid for only 14 days, but the resident continued to receive the IM medication after that period. Progress notes documented IM Geodon administration for agitation, including episodes where the resident was threatening, spitting on people, using a medication cart to hit people, remaining agitated and non-directable, and destroying furniture in the room. The record also showed no baseline EKG and no laboratory work completed before the antipsychotic was started. During interviews, the pharmacist stated he reviewed the antipsychotic medication but did not explain why the resident was not included in the unnecessary medication review list. The DON stated staff who accepted the order no longer worked at the facility. Nursing staff stated the IM order was still active because nurses continued to give it, and one nurse said other nurses had verified it with the Medical Director and psychologist, while another nurse did not confirm personal verification with the physician. The Social Services Director also stated the PASSAR Level I should have been updated to a Level II due to the resident’s aggressive behavior, but it had not been.
Improper Refuse Disposal and Accumulated Debris
Penalty
Summary
Dispose of garbage and refuse properly was cited after surveyors observed refuse being discarded in an unsanitary manner in 2 of 2 refuse areas. During a kitchen tour, debris was seen outside the main dumpster, including gloves, paper, plastic, lids, a paint roller, and a paint can, and a Cook stated he had swept the area a few days earlier. In a separate observation near the emergency exit at the end of the 400 unit, a pile of pallets, discarded furniture, and other unidentifiable refuse was noted by the dumpster, and a later observation showed the piles of refuse and debris had increased. During interview, the Maintenance Director stated that one company picked up specific types of refuse and another company came every other week for additional debris, and acknowledged the refuse had piled up.
Failure to Follow Standard Precautions and Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to follow CDC standard precautions by not ensuring hand hygiene and environmental disinfection during resident care and meal service. For one resident with conversion disorder with seizures, unspecified dementia, psychotic disturbance of mood, mood disturbance, anxiety, and major depressive disorder, a nurse entered the room for blood glucose testing and placed the glucometer supplies on the resident’s meal table without first disinfecting the table. After performing hand hygiene, the nurse completed the blood sugar check, then discarded used paper towels on the same meal table instead of disposing of them elsewhere, and left the room without disinfecting the table. A CNA later placed the meal tray on the same table without first disinfecting it and did not encourage the resident to sanitize hands before eating. A second resident with altered mental status, unspecified dementia, cognitive communication deficit, and encephalopathy had a care plan noting behavioral issues including urinating on the floor, wandering into other residents’ rooms, and eating from other residents’ trays. During lunch observation, the resident had been seen going in and out of other residents’ rooms and touching inside his underwear. Staff placed the lunch tray on the resident’s meal table but did not sanitize the resident’s hands before the meal. The staff member stated he had used a wet paper towel from the bathroom to sanitize the resident’s hands, but when asked to show where it was discarded, he could not produce a trash can in the bathroom or room and did not respond when asked again whether hand sanitation had actually occurred. The facility also failed to follow CDC Enhanced Barrier Precautions for a resident with traumatic subdural hemorrhage without loss of consciousness and dysphagia who required PEG tube medication administration. The resident’s care plan directed staff to use EBP related to PEG tube use, and a CDC EBP poster was posted on the room door with PPE gowns available. During medication administration via the PEG tube, the RN performed hand hygiene and donned gloves but did not don a gown while providing the PEG tube care. When asked why the gown was not worn, the RN responded, "nerves."
LPNs Administered IV Antibiotics Without Required Certification
Penalty
Summary
Licensed Practical Nurses (LPNs) at the facility were found to lack the required competencies and certifications to administer intravenous (IV) antibiotics, as evidenced by record reviews and staff interviews. Specifically, one LPN administered IV antibiotics and performed IV line flushing for a resident without having completed the mandated IV therapy certification and post-graduation training, which includes 30 hours of IV hydration training and 4 hours dedicated to central line care. The facility's professional standards require these certifications for LPNs performing such tasks, but documentation of the required certification for the LPN in question was not provided to the surveyor, despite requests. The resident involved had complex medical needs, including a recent admission with diagnoses such as sepsis following a hospital procedure, acute respiratory failure, alkalosis, and osteomyelitis. The resident was receiving multiple medications, including IV antibiotics, anticoagulants, and opioids. Interviews with staff revealed that LPNs were administering IV medications without the necessary certification, and there was a lack of awareness among some staff and consultants regarding the certification requirements. The Director of Nursing stated that LPNs providing IV care had the required certifications but was unable to produce documentation to verify this for the LPN who administered care to the resident.
Failure to Ensure Dignified Dining and ADL Assistance
Penalty
Summary
The facility failed to ensure that residents were treated in a dignified manner during dining, affecting eight of the sampled residents. Observations revealed that several residents were left waiting for their meals while others at the same table were already eating. For instance, Resident #19 and Resident #90 were observed waiting for their lunch meals while their tablemates were already eating. Similarly, Resident #73 was observed waiting for her lunch meal while her tablemate was eating. Additionally, Resident #83 did not receive her lunch tray until 35 minutes after her roommate had started eating. Interviews with staff indicated that they were educated on serving meals with dignity, yet the practice of serving one table at a time was not consistently followed. The facility also failed to provide necessary assistance with Activities of Daily Living (ADLs) for Resident #73, who has severe cognitive impairment and requires substantial maximum assistance for eating. Observations showed that Resident #73's breakfast and lunch trays were left untouched, indicating a lack of assistance from staff. Despite the care plan highlighting Resident #73's need for significant help during meals, staff interviews revealed inconsistent assistance, with some days Resident #73 eating only 40% of her meals. The MDS Coordinator confirmed that residents coded for substantial maximum assistance require staff to be present to assist them throughout mealtimes.
Inaccessible Emergency Call Lights in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the bathroom emergency call light system was accessible and within easy reach for residents and staff members in a secure, locked unit. This deficiency was observed in the bathrooms of seven residents, where the emergency call cords were either tied around bathroom bars, wrapped around handrails, or missing entirely. These observations were made over a three-day period, and photographic evidence was obtained to document the inaccessibility of the emergency call systems. The residents affected by this deficiency had various medical conditions, including dementia, diabetes, hypertension, schizophrenia, and other cognitive impairments. Their Brief Interview Mental Status (BIMS) scores ranged from severe cognitive impairment to being cognitively intact. Despite their varying levels of cognitive function, all residents were observed to self-propel in their wheelchairs in and out of their bathrooms throughout the day, highlighting the importance of having accessible emergency call systems. Interviews with facility staff, including the Maintenance Director, Housekeeping Director, Director of Nursing, Regional Nurse, Regional Maintenance Director, and the Administrator, confirmed that the emergency call lights should be readily accessible. However, three of the four resident bathrooms remained non-compliant until surveyor intervention. Even after multiple observations, one bathroom's emergency call light remained inaccessible, indicating a persistent failure to address the deficiency.
Failure to Implement Care Plans for PTSD and Anticoagulant Use
Penalty
Summary
The facility failed to implement a care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD) and on anticoagulant medication. The resident, who was admitted post-hospitalization with diagnoses including Unspecified Cirrhosis of Liver, Coronary Artery Disease, Non-Alzheimer's Dementia, and PTSD, had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. Despite these conditions, the facility did not have a care plan addressing the resident's PTSD, as confirmed by the MDS Coordinator during an interview. Additionally, the resident was prescribed Eliquis (Apixaban) for Atrial Fibrillation, with physician's orders to monitor for signs of bleeding due to the anticoagulant. However, the facility did not have a care plan in place to address the anticoagulant use or the associated risk of bleeding. The MDS Coordinator acknowledged the necessity of such a care plan during an interview, highlighting the oversight in care planning for this resident.
Failure to Assist Resident with Vision Services
Penalty
Summary
The facility failed to assist a resident, identified as Resident #89, in obtaining necessary vision services. Resident #89, who was admitted with diagnoses including unspecified dementia with severe cognitive impairment, was noted to require corrective lenses. Despite a family member's request for an eye doctor appointment approximately two months prior, the facility did not arrange for the resident to be seen by an eye doctor. The family member had temporarily provided over-the-counter reading glasses for the resident. Interviews revealed that the Social Service Director (SSD) initially believed the resident had been seen by an eye doctor, but later confirmed that no appointment had been made. The SSD acknowledged the oversight and admitted to not following up with the family member after speaking with the resident, who had severe cognitive impairment. This lack of action resulted in the resident not receiving the necessary vision care as requested by the family member.
Failure to Address Nutritional Needs and Weight Loss
Penalty
Summary
The facility failed to identify and address significant weight loss and provide timely nutritional intervention for two residents, leading to a deficiency in maintaining their nutritional health. Resident #32, who had severe cognitive impairment and multiple diagnoses including muscle wasting and anemia, experienced a weight loss of 8.9% over three months. Despite the resident's low meal intake, averaging 46% from 08/13/24 to 08/30/24, the Clinical Dietitian did not address the weight loss until 24 days after it was identified, delaying necessary nutritional interventions. Resident #7, also with severe cognitive impairment and multiple health conditions, showed a weight loss of 6.55% over six months. The resident's meal consumption varied significantly, with some meals entirely untouched. Despite the resident's fluctuating appetite and low protein levels, the Registered Dietician did not consider the weight loss significant enough to trigger immediate action. The resident's nutritional supplement was only increased after a continued trend of weight loss was observed. Both residents were observed to have inadequate assistance and encouragement during meals, with staff failing to offer alternative food options or ensure the consumption of prescribed nutritional supplements. These inactions contributed to the residents' ongoing nutritional deficiencies, highlighting a lack of timely and effective intervention by the facility's staff and dietitians.
Failure to Follow Tube Feeding Orders
Penalty
Summary
The facility failed to adhere to the physician's orders for tube feeding for a resident with a history of Hemiplegia, History of falling, Muscle Weakness, and Chronic Kidney Disease. The resident was readmitted to the facility with specific orders for enteral feeding using Jevity 1.5 at a rate of 75 ml per hour for 20 hours. However, observations on multiple occasions revealed discrepancies in the amount of formula administered compared to the expected amount based on the prescribed rate. For instance, on one occasion, the feeding bottle was observed to be at the 850 ml mark when it should have been at the 700 ml mark, indicating an over-administration of the formula. The resident experienced a significant weight loss of 9.8% over three months, which was noted by the Clinical Dietitian, who adjusted the feeding orders to continuous feedings due to the weight loss. Interviews with staff revealed that there was a malfunctioning of the tube feeding pump, and bolus feedings were administered to compensate for the feeding needs. The Director of Nursing mentioned that the resident had a behavior of pulling out the feeding tube, which might have contributed to the weight loss, but no documentation was provided to support this claim.
Failure to Assess and Provide Services for PTSD
Penalty
Summary
The facility failed to timely assess and provide appropriate psychosocial services to a resident diagnosed with Post Traumatic Stress Disorder (PTSD). Upon admission, the resident, a veteran with PTSD, was not screened using a standardized tool as per the facility's policy. The resident expressed that loud noises triggered flashbacks related to his wartime experiences. Despite this, the staff, including a Registered Nurse and the Social Service Director, were unaware of the resident's specific triggers and did not engage in discussions about his PTSD. The MDS Coordinator, responsible for care planning, had not initiated a care plan for PTSD, and the resident had not been seen by a psychiatrist until a month after admission. The facility's PTSD policy, which mandates screening and individualized care plans for residents with PTSD, was not followed. The Regional Nurse Consultant confirmed that the facility was not using the PTSD checklist tool, and no residents had been screened for PTSD. The Psychiatrist, who assessed the resident only after the surveyor's inquiry, noted the resident's hallucinations and initiated treatment with Seroquel. The lack of communication and adherence to the facility's policy resulted in a delay in addressing the resident's PTSD needs, highlighting a deficiency in the facility's care processes.
Failure to Provide PTSD Services
Penalty
Summary
The facility failed to provide necessary psychosocial services for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The facility's policy required that all residents be screened for PTSD upon admission using a standardized tool, and those identified with PTSD should receive individualized care plans. However, the facility did not have a PTSD screening tool in use, and the Social Service Director was unaware of her responsibilities regarding PTSD care planning. The resident, a veteran with PTSD, was admitted with a history of flashbacks triggered by loud noises, but his social services evaluation did not include his PTSD diagnosis, and a relevant question on the assessment was marked as not applicable. Interviews with the Social Service Director revealed a lack of understanding and action regarding the resident's PTSD needs. The Director stated she did not handle PTSD cases and incorrectly marked the assessment question about traumatic experiences as not applicable, rather than noting the resident's refusal to answer. The Regional Nurse Consultant confirmed that no PTSD screenings had been conducted due to the absence of a tool, indicating a failure to adhere to the facility's policy and provide appropriate care for the resident's PTSD diagnosis.
Failure to Maintain Accurate Controlled Medication Records
Penalty
Summary
The facility failed to maintain accurate drug records and ensure proper documentation for controlled medications for two residents. Resident #19, who was admitted with diagnoses including obesity and muscle weakness, had a physician's order for Tramadol HCL 50mg to be administered as needed for pain. However, the Medication Administration Record (MAR) for July and August 2024 did not document the administration of Tramadol on specific dates, despite the Medication Monitoring / Control Record indicating it was given. Interviews with staff revealed lapses in documenting the date and time on the Medication Monitoring / Control Record, with staff acknowledging the oversight. Similarly, for Resident #306, who was admitted with conditions such as hemiplegia and type 2 diabetes, there was an order for Oxycodone HCL 5mg to be given as needed. The Medication Monitoring / Control Record showed the medication was signed out without indicating the date or time, although the MAR documented its administration on a specific date in September 2024. Staff interviews confirmed the failure to complete the Medication Monitoring / Control Record accurately, citing distractions as a possible reason for the incomplete documentation.
Inappropriate Diet Consistency for Mechanical Soft Diet
Penalty
Summary
The facility failed to provide the appropriate diet consistency for residents on a mechanical soft diet, specifically affecting two residents during dining observations. The facility's 'National Dysphagia Diet Level 3 Advanced' guidelines require that food be served moist and in bite-size pieces less than 1 inch long, avoiding hard, sticky, or crunchy foods. However, during a dining observation, Resident #73, who had severe cognitive impairment, was served cooked red cabbage in strips of approximately 2-3 inches, which was difficult to cut and not suitable for the mechanical soft diet. This resulted in the resident coughing after consuming the cabbage. Similarly, Resident #41, who had moderate cognitive impairment, was observed eating a meal in his room without staff supervision, which included cooked red cabbage pieces of 2-3 inches long, inconsistent with the mechanical soft diet requirements. The Speech Language Pathologist confirmed that the red cabbage served was inappropriate for the diet consistency and discussed the issue with the Clinical Dietitian and Dietary Manager, noting that the cabbage was not cooked enough to meet the dietary guidelines.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during a survey of the Main Kitchen. During the inspection, small flying insects were observed in the dishwashing area near an open garbage dumpster, and a drainage treatment system was found disconnected. The Kitchen Manager acknowledged the presence of insects and attempted to connect the treatment system. Additionally, the walk-in refrigerator was found to have an internal temperature of 55 degrees Fahrenheit, above the recommended 40 degrees Fahrenheit or below, with water condensation present and carton boxes feeling wet. The Kitchen Manager removed the internal thermometer, suspecting it was faulty. Similarly, a reach-in freezer in the Dry Storage Room showed a temperature of 38 degrees Fahrenheit instead of the recommended 0 degrees Fahrenheit or below, leading the Kitchen Manager to remove its thermometer as well. Further deficiencies were noted in food storage practices. An opened package of frozen tortillas in the walk-in freezer was not labeled or dated for expiration. In the Dry Storage Room, an opened package of cheesecake filling was found at the bottom of a box, which the Dietary Manager discarded and cleaned. Additionally, an incident involving Staff D, an Activity Coordinator, was observed where she failed to wash her hands after touching personal items before continuing to feed a resident, compromising food safety and hygiene standards.
Inaccurate MDS Assessments for High-Risk Medications
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents regarding their use of high-risk medications. For one resident, the MDS assessment incorrectly documented the use of an anticoagulant, despite the resident only being prescribed aspirin 81 mg for coronary artery disease, which should have been classified as an antiplatelet. The MDS Coordinator acknowledged the error, stating that aspirin at this dosage was not considered an antiplatelet, which led to the incorrect classification. For the second resident, the MDS assessment inaccurately indicated the use of an anticoagulant, although the resident had no orders for anticoagulants or antiplatelets. The resident was receiving Procrit injections for anemia, which the MDS Coordinator mistakenly associated with anticoagulant use. The MDS Coordinator admitted to being overwhelmed and confused about the medication classifications, leading to the errors in the MDS documentation for both residents.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lauderhill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center At Inverrary | 0.9 mi | ★★★★★ | 0 | 0 |
| Palms Care Center And Rehab | 0.9 mi | ★★★★★ | 8 | 0 |
| Nspire Healthcare Plantation | 1.4 mi | ★★★★★ | 14 | 0 |
| St Johns Nursing Center | 1.8 mi | ★★★★★ | 2 | 0 |
| Plantation Nursing & Rehabilitation Center | 2.5 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.