Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Plantation during CMS and state inspections, most recent first.
Food Storage and Preparation Sanitation Deficiencies: Staff were observed handling open foods while wearing a watch, failing to perform hand hygiene when changing gloves, and touching their face before donning clean gloves. Surveyors also noted damaged utensils, food residue on equipment, dust on vents, improper storage of a personal cell phone and eggs above ready-to-eat foods, peeling skillet coating, and a mold-like substance in the water spout of an ice and water machine.
Failure to Maintain Resident Dignity During Morning Care and Mealtime Assistance: A cognitively intact resident who needed help with bathing and dressing was found naked in bed with the call light out of reach after a CNA left and did not return, while two other residents who needed eating assistance were observed being fed by CNAs who stood over them during meals. One resident had CVA-related diagnoses and dysphagia, and the other was on hospice with dementia and required partial to moderate help with eating.
Call lights were not kept within reach of three residents while they were in bed. One resident with dementia and upper extremity impairment did not know where the call light was, another resident’s call light was hanging on the side of the bed and out of reach, and a third resident’s call light was found on the floor behind the bed. The residents were observed in bed with their HOB raised, and one resident also had water placed out of reach.
Failure to honor resident choice for out-of-bed care and showers: One resident with severe cognitive impairment and a feeding tube was repeatedly observed remaining in bed despite a physician order and family request to be out of bed daily, while staff said the MAR check marks reflected attempts rather than confirmed out-of-bed care and there was no supporting documentation of refusal. Another resident with severe cognitive impairment and respiratory/cardiac diagnoses was scheduled for showers but family and the resident reported she had received only one shower, and the DON could not produce documentation of refusals or completed showers.
A resident with severe cognitive impairment, dementia, gait instability, and a history of falls was observed sitting in a wheelchair with the chair pushed against a wall and a table placed over her upper legs, preventing her from rising normally. She repeatedly tried to stand but could not fully rise, and no staff checked on her for about 30 minutes. Staff later denied placing her in that position, while an LPN said the resident had been declining and was ambulatory with assistance of the wheelchair and side rails.
Weekend Dining Room Closure Did Not Honor Resident Preferences: The facility kept the dining room closed on weekends and told residents they had to return to their rooms, despite multiple residents stating they wanted the option to eat lunch in the dining room every day. During observation and interview, residents said they enjoyed the socialization and preferred dining in the main dining room on Saturdays and Sundays, while the ADM and DON stated the room had been closed since COVID and residents had not yet been polled about reopening it.
A resident with rheumatoid arthritis, generalized muscle weakness, and diabetic polyneuropathy was fully dependent on staff for bed-to-chair transfers, yet a CNA used a Hoyer Lift to move the resident from bed to wheelchair without another staff member present. The resident was observed strapped to the lift in mid-air during the transfer, and an LPN stated the transfer should not have been done without assistance.
The facility failed to follow its catheter care policy for two residents with indwelling catheters. One resident had a physician order for a leg strap, but staff observed no strap in place and the tubing was left hanging. For another resident, the catheter bag and tubing were observed on the floor, and during Foley care CNAs cleaned the tubing in the wrong direction and stated they had no anchor for the tubing. The DON reviewed the findings with surveyors.
The facility failed to maintain a current physician order for oxygen for one resident, failed to include oxygen therapy in that resident’s care plan, and failed to date oxygen tubing, cannula, and mask for two residents. One resident with severe cognitive impairment and respiratory failure had oxygen documented in nursing notes, but the order had been discontinued and the care plan lacked respiratory interventions; observations also found undated tubing and the cannula not in place. Another resident with respiratory failure and CHF had weekly tubing/mask changes not documented as ordered, and oxygen/nebulizer supplies were observed stored in bags with missing dates.
Failure to identify PTSD triggers and complete person-centered care plans for two residents with PTSD-related behaviors. One resident reported triggers such as loud noises and bright lights, but the DON was unaware of them and the SSD said he did not specifically ask what would trigger an event. The other resident’s record listed PTSD, but the care plan had no PTSD interventions or triggers; staff could only guess at possible triggers, and the SSD and MDS Coordinator had not completed a resident-specific PTSD care plan.
Medication administration errors resulted in an 8% error rate, above the 5% limit. During a med pass for a resident with DVT, HTN, and anxiety, an LPN held Metoprolol because the BP was 92/67 even though the order had no parameters and no MD was called, then gave only one Buspirone tablet instead of the ordered two before correcting the dose after the surveyor questioned the order.
F812 food procurement, store, prepare and serve was cited again after QAPI failed to show effective plans of action for repeated kitchen-related deficiencies. Survey history showed the facility had been cited for the same deficiency on multiple prior recertification surveys, and the Administrator stated there was no PIP, education, or audits being done regarding kitchen sanitation.
A nurse failed to perform hand hygiene during medication administration for two residents, including after leaving a room with an EBP sign and before and after giving meds to another resident. In a separate observation, an LPN did not disinfect a BP cuff before or after using it on three residents, despite stating it should be cleaned after each use.
The facility failed to maintain food safety standards, with damaged utensils and unsanitary conditions noted in the kitchen. Additionally, staff did not adhere to proper hand hygiene practices, failing to wash hands before donning gloves after potential contamination. These deficiencies were observed during a kitchen tour, highlighting a lack of adherence to professional standards.
A resident with multiple health issues, including a pressure ulcer and surgical wound, did not receive timely wound care as per physician's orders. The resident's dressing was not changed for three days, despite the care plan requiring daily treatment. The Wound Care Nurse admitted to not performing the treatment and expected floor nurses to do so, leading to a lapse in care.
A resident with a history of serious medical conditions was given the wrong type of Aspirin by an RN, who administered a chewable tablet instead of the prescribed delayed-release form. The error was confirmed by the facility's pharmacist and DON, who noted the importance of administering the correct medication as per the physician's order.
The facility failed to maintain accurate records for two residents, leading to deficiencies in wound care and end-of-life documentation. One resident did not receive a documented dressing change as ordered, and the Wound Care Nurse signed off on the treatment without performing it. Another resident's passing was inadequately documented, with only the time of death recorded and no further notes, despite family presence.
The facility failed to follow Enhanced Barrier Precautions (EBP) during medication administration for a resident with a PEG tube, as an LPN did not wear the required PPE. PPE gowns were unavailable for residents on EBP, and appropriate signage was missing. Additionally, hand hygiene was not properly performed during a blood glucose check, and a CNA's unsecured hair posed a cross-contamination risk during perineal care for a resident with a UTI.
Three residents in an LTC facility reported significant delays in call light responses, particularly during night shifts and weekends. Despite being cognitively intact, they experienced waits of 30 to 60 minutes or more, with staff often passing by without checking in. This issue was reported to nurses and discussed in resident council meetings, indicating a chronic problem with call light response times.
Food Storage and Preparation Sanitation Deficiencies
Penalty
Summary
The facility failed to store and prepare food in a sanitary manner in accordance with professional food safety standards. During the initial kitchen tour, a staff member was observed handling open foods while wearing a watch, and another staff member failed to perform hand hygiene when changing single-use gloves. Additional observations included damaged utensils stored over a three-compartment sink, an accumulation of ice in an ice cream freezer, a glue trap placed directly over equipment in the ware washing area, food processor blades encrusted with food residue, a mop stored so contaminated water could run down the handle, dust on an air conditioning vent over dry storage products, a personal cellular device and a flat of eggs stored above commercially processed and ready-to-eat foods in the walk-in refrigerator, and peeling Teflon coating on skillets. The staff member present acknowledged understanding of the concerns at the conclusion of the tour. On the follow-up kitchen tour, dust was again noted on air conditioning vents attached to the exhaust system over cooking equipment. A dietary aide was observed donning a beard restraint with a bare hand, then touching his face before putting on clean single-use gloves; the surveyor intervened, and the dietary manager instructed the aide to perform hand hygiene and don new gloves. During a tour of the first-floor unit pantry, a mold-like substance was observed in the water spout of the combination ice and water machine, and the dietary manager acknowledged the concern at the time of observation.
Failure to Maintain Resident Dignity During Morning Care and Mealtime Assistance
Penalty
Summary
The facility failed to provide care and services in a dignified manner for one resident during morning care. The resident had diagnoses including rheumatoid arthritis, generalized muscle weakness, and type 2 diabetes with diabetic polyneuropathy, and the MDS indicated the resident was cognitively intact with a BIMS score of 15. The care plan documented dependence for bathing and partial to moderate assistance for dressing above the waist, with staff to assist with bathing/showering and encourage use of the call bell for help. During a morning tour, the resident was found in bed naked and covered only by a towel that barely covered the torso, while attempting to put on a shirt and having difficulty raising the arms. The privacy curtains were closed, but no staff were in the room. The overbed table was away from the resident, a basin with cool water and a wash towel were on the table, sheets and a blanket were on the floor, and the call light was hanging off the side of the bed and not within reach. The resident stated the CNA had left her in bed and told her she would be right back, but had not returned. The facility also failed to honor residents' dignity during dining assistance for two residents who required help with eating. One resident had diagnoses including cerebral infarction, dysphagia, and need for assistance with personal care, and the MDS showed substantial to maximal assistance was needed for eating. A CNA was observed standing over the resident while feeding her, with the bed raised high to the CNA's waist. Another resident, under hospice care with diagnoses including cerebral atherosclerosis, unspecified dementia, anxiety, and palliative care, had a BIMS score of 8 and needed partial to moderate assistance for eating. A CNA was observed feeding this resident breakfast while standing up. Staff stated they knew they should not be standing while assisting with meals, but did so because it was easier to feed the residents that way.
Call lights not accessible to residents in bed
Penalty
Summary
The facility failed to ensure call lights were accessible to residents while they were in bed for 3 of 22 sampled residents. The deficiency was identified during observations, interviews, and record reviews related to resident access to the call system and the ability to request staff assistance from bed. The facility policy stated that call lights should be within reach and accessible to residents while in their bed or other sleeping accommodations. Resident #42 had diagnoses including dementia, generalized muscle weakness, need for assistance with personal care, and hydronephrosis with renal and ureteral calculous obstruction. The resident’s MDS showed a BIMS score of 09 and upper extremity impairment on one side. During observation, the resident was in bed with a hospital gown and the head of bed raised; a foam cup of water was on the dresser near the bathroom entrance and not within reach, and the call light was laying on the floor on the left side of the bed. When asked to use the call light to request water, the resident stated he would use it but did not know where it was. Resident #92 had diagnoses including displaced intertrochanteric fracture of the right femur, need for assistance with personal care, chronic kidney disease stage 3, and dementia. The resident’s MDS showed a BIMS score of 13 and no upper extremity impairment. During observation, the resident was sleeping in bed with the head of bed raised, and the call light button was hanging on the side of the bed and not within reach; the foam cup of water on the bedside table was also not within reach. Resident #104 had diagnoses including rhabdomyolysis, hydronephrosis, cardiomegaly, and acute kidney failure, with a BIMS score of 15 and no upper extremity impairment. During observation, the resident was in bed with the head of bed raised and stated she could use the call light, but the call light button was found on the floor behind the bed.
Failure to Honor Resident Choice for Out-of-Bed Care and Showers
Penalty
Summary
The facility failed to honor a resident’s right to self-determination by not ensuring the resident was out of bed daily as ordered and requested by family. Resident #115 was admitted with traumatic subdural hemorrhage without loss of consciousness, need for assistance with personal care, and dementia, and had a BIMS score of 4 indicating severe cognitive impairment. The physician ordered the resident to get up and out of bed daily as tolerated, and the resident’s family requested that she be out of bed daily to participate in activities because she was described as a social butterfly. However, repeated observations over several days found the resident in bed wearing a hospital gown, holding her blanket, and not dressed or out of bed, including times when no staff entered the room except to start tube feeding. Staff interviews showed the resident had not been gotten out of bed by assigned CNAs, and one CNA stated the resident has a feeding tube and does not usually get out of bed. An LPN stated the resident had not been gotten out of bed, but said the MAR check marks represented attempts to do so. The DON stated that a check mark in the MAR meant the resident was out of bed or there was an attempt, and if the resident refused, the doctor needed to be called and the refusal documented in progress notes. PT notes referenced that the resident sometimes did not want to participate in treatment, but there was no documentation that she refused to get out of bed, and nursing progress notes for March 2026 did not document refusal or notification from PT. The facility also failed to provide showers as scheduled and as requested for another resident. Resident #108 was admitted with heart failure, COPD, and acute and chronic respiratory failure with hypoxia, and had a BIMS score of 6 indicating severe cognitive impairment. The resident required substantial to maximum assistance with showering and bathing. A family member reported the resident had received only one shower since admission and was scheduled for showers twice weekly. The DON stated the resident refused showers, but could not produce documentation of refusals, a care plan for refusals, or progress notes documenting whether showers were received. The DON also stated the issue could not be documented in the EHR and that they needed to come up with a way to document it. When interviewed in Spanish, the resident stated her primary language was Spanish and said she would like showers and believed she had only had one shower since admission.
Physical restraint used by positioning table over resident’s legs
Penalty
Summary
The facility failed to provide an environment free from physical restraints for one resident. The facility policy stated that residents should be free from physical or chemical restraints unless needed for medical treatment, and defined a physical restraint as a device or method that restricts freedom of movement or normal access to the body, including devices used with a chair that the resident cannot remove and that prevent rising. Resident #106 had severe cognitive impairment on the most recent quarterly MDS, was not interviewable, and had diagnoses including dementia, anxiety disorder, encephalopathy, gait and mobility abnormalities, muscle weakness, dysphagia, heart failure, hypertension, diabetes, and a history of left hip dislocation and artificial left hip joint. The resident’s care plan documented deficits related to activity intolerance, fatigue, impaired balance, history of multiple falls, and dementia, and stated that the resident was able to turn self in bed and transfer self. The falls care plan identified poor balance, psychoactive drug use, and unsteady gait, and included interventions such as activities to promote exercise and strength building and 1:1 activities if bedbound. During observation, the resident was sitting in a wheelchair in the activity/dining room with the wheelchair pushed against the wall and a table positioned directly over her upper legs. The resident repeatedly attempted to rise from the wheelchair but could not rise to a complete upright position, and the table began to tilt on its base several times as she tried to stand. The resident remained in that position for approximately 30 minutes with no staff entering the room to check on or interact with her, and it was unknown how long she had been positioned that way before the observation began. A blanket was placed on the table in front of the resident, but she showed no interest in it and there were no other means to keep her occupied. When the concern was brought to an LPN, the resident was assisted to the nurse’s station. Multiple CNAs interviewed afterward denied positioning the resident that way, while one CNA stated the resident could walk but needed to be monitored because it was dangerous for her. The LPN stated the resident had been declining, had been placed on hospice for safety, and was ambulatory with assistance of the wheelchair and side rails.
Weekend Dining Room Closure Did Not Honor Resident Preferences
Penalty
Summary
The facility failed to provide an environment that supported residents’ quality of life by not honoring resident preferences for the dining room to be open for meals on weekends. During an unannounced survey, the surveyor observed residents in the dining room participating in an activity and heard the activity director tell them they would have to return to their rooms because the dining room was closed on weekends. The dining room had been closed since around March 2023, and the Administrator stated it remained closed because residents had not complained about it being closed. During a dining observation, 8 of 16 residents in the main dining room for lunch stated they wanted the option to eat there every day, including Saturdays and Sundays. Residents #12, #14, #65, #20, #9, #73, #75, and #3 each stated they enjoyed eating in the dining room and would like it open on weekends as well. One resident said she liked lunch in the dining room because she could socialize with other residents, another said she enjoyed seeing a different room before going outside, and another resident’s aide stated it was nice for him to have the option to eat with other residents on weekends. The Administrator and DON were asked about the weekend closure and stated they had not yet polled residents about whether they wanted the dining room open on weekends.
Improper One-Person Hoyer Lift Transfer
Penalty
Summary
The facility failed to appropriately use a two-person transfer with a Hoyer Lift during a bed-to-wheelchair transfer for Resident #22. Resident #22 was admitted and readmitted with diagnoses including rheumatoid arthritis, generalized muscle weakness, and type 2 diabetes mellitus with diabetic polyneuropathy. The resident’s MDS showed a BIMS score of 15, indicating cognitive intactness, and section GG indicated the resident was fully dependent on staff for transfers between bed and chair or wheelchair. The care plan documented ADL deficits related to activity intolerance, fatigue, impaired balance, limited mobility, limited ROM, and pain, and stated that the resident was totally dependent on staff for transferring. On observation, Staff D, CNA, entered the resident’s room with a Hoyer Lift and later transferred the resident from bed to wheelchair without another staff member present. The resident was observed strapped to the lift in mid-air while Staff D used the remote control to move the resident toward the wheelchair. About 20 seconds later, Staff C, LPN, entered the room and stated that Staff D should not have been transferring a resident using the Hoyer Lift without another staff member assisting. Staff D later stated that the Hoyer Lift is to be used with two staff present for transfers, and another CNA stated the protocol is to dress the resident, leave them in bed, then get another staff member to assist with the Hoyer Lift transfer.
Catheter care and tubing management not followed
Penalty
Summary
The facility failed to follow its catheter care policy for residents with indwelling catheters. The policy stated that leg bags may be used per request and that leg bags must be attached to the resident’s thigh or calf with slack in the tubing to minimize pressure and tension, with straps snug but not tight. It also stated that catheter care should include wiping from the urinary meatus outward and holding the catheter in place so it is not pulled. For one resident with diagnoses including metabolic encephalopathy, respiratory failure, and prostate cancer, the MDS showed severe cognitive impairment and an indwelling catheter. A physician order dated 02/12/26 directed staff to use a leg strap to anchor the catheter every shift, and the MAR showed initials and check marks indicating the order was followed. However, during an observation on 03/03/26, the resident’s catheter tubing was not strapped to the leg, and no strap was present on either leg or calf. A CNA stated the resident had never had any strap and that staff just let the catheter tubing hang. For another resident with diagnoses including metabolic encephalopathy, chronic kidney disease stage 3, obstructive and reflex uropathy, and urinary retention, the MDS showed severe cognitive impairment and a physician order also directed use of a leg strap to anchor the Foley catheter. Observations on 03/01/26 and 03/02/26 showed the catheter bag and tubing lying on the floor-fall-mat next to the bed. During observed Foley care on 03/03/26, CNAs cleaned the penis and tubing, but the tubing was wiped from the distal end toward the urinary meatus instead of starting at the meatus and moving outward. The CNAs stated this was how they had been educated, and they did not have an anchor for the tubing.
Oxygen Orders, Care Plans, and Equipment Dating Not Maintained
Penalty
Summary
The facility failed to ensure a current physician order for oxygen for Resident #10, who was admitted with diagnoses including obstructive and reflux uropathy and acute and chronic respiratory failure with hypoxia. The resident’s MDS indicated severe cognitive impairment and substantial maximal assistance with personal hygiene. Although a physician order dated 01/05/26 documented oxygen at 2 liters per minute via nasal cannula every shift for shortness of breath, that order was later discontinued on 01/27/26. A pulmonary consultation dated 02/06/26 documented scattered rhonchi and wheezing, diminished breath sounds on the right, and a plan to initiate immediate oxygen therapy to maintain SpO2 greater than 92%. Nursing documentation showed oxygen administration by staff on multiple dates in late February and early March, but the resident’s nursing care plan did not include documentation for respiratory care and oxygen therapy. During observations, Resident #10’s oxygen concentrator was on and making a very loud sound, the bubble indicator showed 1.5 liters per minute, the long oxygen tubing was undated, and the nasal cannula was not on the resident’s nares. Staff interviews indicated that oxygen therapy requires a physician order, that tubing, cannula, and mask are changed according to the physician order, and that a nursing care plan is needed for oxygen therapy and nebulizing treatment. The facility also failed to ensure oxygen tubing, nasal cannula, and mask were dated for Resident #35, who had diagnoses including prostate cancer, respiratory failure, and diastolic congestive heart failure. The resident’s MDS indicated severe cognitive impairment and dependence for toileting. Physician orders included oxygen via nasal cannula at 2 liters continuously for shortness of breath and an order to change tubing, mask, and/or nasal cannula weekly and as needed. Review of MAR/TAR documentation showed missed weekly changes in early and mid-February, and observations found the oxygen concentrator turned off, tubing stored in a plastic bag with dates written on it, and nebulizing equipment with tubing and mask inside a plastic bag that were not dated. Staff stated that treatment documentation was done electronically and that the date of tubing and mask changes should be documented on the plastic bag.
Failure to Identify PTSD Triggers and Complete Person-Centered Care Plans
Penalty
Summary
The facility failed to appropriately identify PTSD behavior triggers and implement person-centered care plans for two residents with PTSD-related behaviors. One resident reported severe PTSD related to an automobile accident and a childhood incident, and told the surveyor that loud noises and bright lights were triggers. The resident also stated he had never discussed his triggers with anyone in the facility and expressed concern about not receiving proper PTSD medications. The DON stated she was unaware the resident had specific PTSD triggers, and the SSD acknowledged that although he completed PTSD assessments, he did not specifically ask what would trigger an event. The MDS Coordinator stated she initiated the PTSD care plan and that the SSD was responsible for adding specific triggers, but the care plan did not contain them. The record for the second resident showed diagnoses including major depressive disorder, sedative, hypnotic or anxiolytic dependence, and schizoaffective disorder bipolar type, and a care plan dated 03/04/23 documented psychotropic medication use related to schizophrenia, bipolar disorder, PTSD, and nightmares. However, the care plan did not document any PTSD interventions or triggers. During interview, the resident stated that stress and being asked questions made her feel unsafe or insecure, and she said staff were aware of her triggers. An LPN who had cared for the resident did not know the PTSD diagnosis or the resident’s triggers and could only guess that opening the door might be a trigger. The SSD stated he had not initiated a nursing care plan for the second resident’s PTSD and said he would start soon. The MDS Coordinator stated she was still in the process of completing the assessment after the PTSD diagnosis and that the PTSD care plan would be added later, but she had not spoken with the resident about the diagnosis and did not know the triggers. She also stated she did not remember why a PTSD care plan had not been initiated earlier despite the diagnosis being documented in the record. The interviews and record review showed that both residents had PTSD-related needs identified, but their specific triggers were not incorporated into the care plans at the time of survey.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication administration errors resulted in an 8 percent medication error rate, exceeding the 5 percent threshold. During observation of medication pass for Resident #119, whose record showed admission on 01/30/26 and diagnoses of Deep Venous Thrombosis, Hypertension, and Anxiety Disorder, the resident was cognitively intact with a BIMS of 15. The LPN checked the resident’s blood pressure before giving medications and found it was 92/67, then decided not to administer Metoprolol Tartrate because the blood pressure was low, even though the order had no parameters and no physician was called before the medication was held. The LPN then prepared and administered Klonopin, Buspirone, Escitalopram, and Apixaban, but initially gave only one Buspirone tablet instead of the ordered two tablets; after the surveyor questioned the order, the LPN realized the error and gave an additional Buspirone tablet.
Repeated F812 Deficiency and Lack of QAPI Follow-Through
Penalty
Summary
F812 food procurement, store, prepare and serve was cited again after the facility’s QAPI activities failed to show effective plans of action to correct repeated quality deficiencies in the kitchen area. Survey history showed the facility had previously been cited for F812 on multiple recertification surveys with exit dates of 12/2020, 02/2022, 06/2023, and 08/22/2024. During an interview on 03/04/26 at 1:20 PM, the Administrator stated there was no Performance Improvement Plan (PIP) in place for this deficiency and that no education or audits were being done regarding kitchen sanitation. The repeated deficient practice was identified as having the potential to affect all 110 residents in the facility at the time of the survey.
Infection Control Lapses During Medication Administration and Equipment Use
Penalty
Summary
The facility failed to perform appropriate hand hygiene during medication administration for two residents. During an observed medication pass, a registered nurse left one resident’s room while an Enhanced Barrier Precaution sign was posted on the door, went directly to the medication cart without performing hand hygiene, prepared medications for another resident, entered that resident’s room, and gave the medications without performing hand hygiene before or after the administration. The nurse then left the room without performing hand hygiene. When interviewed, the nurse acknowledged having infection control training but did not respond when asked why hand hygiene was not performed. The facility also failed to properly disinfect a blood pressure cuff during medication administration for three residents. A licensed practical nurse was observed taking blood pressures on three residents and was not seen sanitizing the blood pressure equipment before or after use on any of them. When asked how often the blood pressure cuffs should be cleaned, the nurse stated they should be cleaned after each use and said, "I should have cleaned it." The facility policy reviewed stated that hands should be washed prior to administering medications and after observing resident consumption of medications, and that multi-resident equipment should be cleaned and disinfected after each use before being used for another resident.
Food Safety and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to prepare and serve food in a sanitary manner, as observed during a kitchen tour. Several issues were noted, including damaged kitchen utensils that were no longer easily cleanable, an accumulation of food residues on a manual can opener, dust on an air conditioning vent over the food assembly area, and damage to the wall and missing tiles around the walk-in cooler door. These conditions indicate a lack of adherence to professional standards for food safety. Additionally, the facility's hand hygiene policy did not specifically address kitchen and food safety concerns, leading to multiple instances of staff failing to perform proper hand hygiene. Several dietary aides and a cook were observed not washing their hands before donning gloves after potential contamination, such as handling a wet floor sign, cleaning a cart with bare hands, and returning from breaks or other areas. These actions were acknowledged by the staff involved, and the surveyor intervened to stop them from continuing work until proper hand hygiene was performed.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to adhere to the physician's orders for wound treatment and did not provide timely wound care for a resident with multiple diagnoses, including acute osteomyelitis, type 2 diabetes mellitus, and dependence on renal dialysis. The resident, who was cognitively intact, had a pressure ulcer and a surgical wound on the left foot. The care plan required daily wound treatment and monitoring, but the facility did not follow these orders. The resident expressed concern about the lack of dressing changes, and an observation confirmed that the dressing had not been changed since three days prior. The Treatment Administration Record indicated that the wound treatment was signed off for two days, but there was no record for the following day. The Wound Care Nurse admitted to not seeing or changing the resident's dressing on the day in question and acknowledged that the dressing had not been changed as required. The nurse also noted that floor nurses were expected to perform the treatment if she did not. This lapse in care was confirmed by photographic evidence and the nurse's acknowledgment of the oversight.
Incorrect Aspirin Administration
Penalty
Summary
The facility failed to administer the correct type of Aspirin medication to a resident, as per the physician's order. During a Medication Administration Observation, a Registered Nurse (RN) was observed administering a chewable pink-colored Aspirin 81mg tablet instead of the prescribed yellow-colored Aspirin 81mg Delayed Release/Enteric coated tablet. The RN did not separate the chewable Aspirin into a different cup or inform the resident that it should have been chewed. This error was noted during a review of the facility's medication administration procedures, which emphasize the importance of checking the medication against the order before administration. The resident involved had a history of multiple medical conditions, including Cerebral Infarction, Endocarditis, and Coronary Artery Disease, and was cognitively intact with a Brief Interview Mental Status score of 15. Interviews with the resident, the RN, the facility pharmacist, and the Director of Nursing confirmed the error. The pharmacist highlighted the difference in absorption methods between the two types of Aspirin, emphasizing that the correct medication should have been administered as ordered.
Deficiencies in Wound Care and End-of-Life Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in wound care documentation and end-of-life documentation. For one resident, who was admitted with conditions including acute osteomyelitis and diabetes, there was a failure to document wound care accurately. The resident expressed concern about the lack of recent dressing changes, and an observation confirmed that the dressing had not been changed as per the physician's orders. The Wound Care Nurse admitted to not performing the dressing change on a specific date but had signed the Treatment Administration Record (TAR) as if the treatment had been completed. In another case, the facility did not adequately document the passing of a resident who had multiple medical conditions, including heart failure and dementia. The nursing progress notes only recorded the time of death, with no further documentation on the day of or the day following the resident's passing. Interviews with the Social Services Director and the Director of Nursing revealed a lack of awareness and documentation regarding the resident's death, despite the presence of the resident's family at the time.
Infection Control and PPE Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) during medication administration for a resident with a PEG tube, as observed when a Licensed Practical Nurse (LPN) entered the resident's room without donning the required Personal Protective Equipment (PPE). The LPN administered medication without wearing a PPE gown, despite the resident being under EBP due to the presence of a PEG tube. The corporate nurse later acknowledged that PPE should be worn during such procedures. Additionally, the facility did not ensure the availability of PPE gowns on the 2nd floor for residents under EBP. Observations revealed that PPE containers were not stocked with gowns, and staff were seen providing care without donning PPE. The Director of Maintenance admitted to not placing the order for gowns in time, and the Infection Preventionist acknowledged the oversight in restocking the containers. The facility also failed to post appropriate EBP signage for a resident with a PEG tube, which was necessary to inform staff of the required precautions. Furthermore, during a blood glucose check for another resident, an LPN did not perform hand hygiene and improperly disposed of a used lancet. In a separate incident, during perineal care for a resident with a UTI, a CNA's unsecured hair came into contact with the resident's skin, posing a risk of cross-contamination.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to ensure timely response to call lights for three residents, leading to unmet needs and preferences. Resident #38, who is cognitively intact with a BIMS score of 15, reported multiple complaints about delayed call light responses, particularly on weekends. During interviews, Resident #38 stated that staff often passed by without checking in, and it sometimes took 45 minutes to an hour for the call light to be answered. This issue was reported to the nurses and discussed during resident council meetings. The call light was checked and found to be functioning properly. Resident #13, also with a BIMS score of 15, expressed similar concerns about delayed call light responses, especially during the night shift from 11:00 PM to 7:00 AM, with waits of 30 to 60 minutes. Resident #55, with a BIMS score indicating intact cognition, reported that call lights were typically answered about an hour later, particularly at night. Resident #55 used the call light primarily for assistance with changing. These delays in response times were consistent across the residents' reports, indicating a chronic issue with call light response in the facility.
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What surveyors actually found near you
We read the 403 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Plantation
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nspire Healthcare Lauderhill | 1.4 mi | ★★★★★ | 14 | 0 |
| Broward Oaks Nursing And Rehabilitation | 1.9 mi | ★★★★★ | 0 | 0 |
| Life Care Center At Inverrary | 2.1 mi | ★★★★★ | 0 | 0 |
| Palms Care Center And Rehab | 2.3 mi | ★★★★★ | 8 | 0 |
| Springtree Rehabilitation & Health Care Center | 2.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.