Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pearl At Fort Lauderdale Rehabilitation And Nursin during CMS and state inspections, most recent first.
The facility failed to maintain food safety and sanitation standards, affecting 187 residents. Observations included unclean kitchen equipment, improper food labeling, and a dietary aide preparing food without a beard covering. The dishwasher temperature exceeded the manufacturer's recommended limit, and a stock pot had residue buildup. These issues indicate non-compliance with professional food service standards.
The facility's QAPI/QAA failed to implement an effective plan to correct deficiencies in Resident Rights (F550), Nutrition (F692), Pharmacy Services (F755), Meal Frequency (F809), and Infection Control (F880). These issues were previously cited and identified again, potentially affecting all 196 residents. No effective corrective plan was evident during the QAPI review.
The facility failed to maintain resident dignity during dining by referring to residents as 'feeders' and standing while feeding them. Staff were observed using disrespectful terminology and not sitting at eye level when assisting residents with meals, contrary to the facility's policy on dignity.
The facility failed to accurately complete MDS assessments for three residents, leading to deficiencies in documenting medications and diagnoses. A resident with nicotine dependence was observed smoking despite having a nicotine patch, which was not coded as a psychotropic medication. Another resident's MDS was incorrectly coded for Schizophrenia instead of Schizoaffective Disorder, Bipolar Type. A third resident's MDS was inaccurately coded for anticoagulant use, despite no physician order, and failed to document other medications administered.
The facility failed to implement comprehensive care plans for residents on psychotropic medications and antibiotic therapy, leading to deficiencies in monitoring and addressing their needs. A resident on Trazodone lacked orders for side effect monitoring, while another on Meropenem had inadequate IV site maintenance. Other residents on psychotropic medications also had care plan deficiencies, indicating systemic issues in care planning and monitoring.
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in care. A resident with cognitive impairment was left without assistance during meals, consuming only a small portion of food. Another resident with multiple health issues received inadequate oral care, resulting in dry and cracked lips. A third resident expressed dissatisfaction with grooming, while two others struggled to eat without staff support. These incidents highlight the facility's failure to adhere to care plans and provide necessary support.
A resident with a urinary catheter experienced blood-tinged urine, but the facility failed to document or address the issue. Observations showed improper infection control practices, such as placing the urinary bag on the floor and not changing gloves between tasks. Interviews revealed a lack of communication and documentation by staff, contributing to the deficiency.
The facility failed to calibrate scales and provide timely nutritional supplements, leading to significant weight loss in two residents. One resident with chronic kidney disease lost 17% of their weight over two months, and another with multiple diagnoses lost 13.6% over less than six months. The dietitian delayed increasing supplements, and scales had outdated or missing calibration stickers, potentially affecting weight accuracy.
The facility failed to obtain current physician's orders and maintain proper documentation for the care of IV/PICC lines for three residents. One resident had a PICC line with a stained, peeling dressing and no maintenance orders. Another resident's PICC line lacked specific orders for dressing changes and flushing, with no care plan in place. A third resident had an IV catheter left in place after antibiotic therapy completion, with loose dressing and no documentation of care. Staff interviews revealed a lack of knowledge and communication regarding the care and maintenance of these lines.
A facility failed to obtain current physician's orders for oxygen therapy for a resident with COPD and did not properly monitor another resident receiving nebulizer treatments. The resident receiving oxygen therapy was observed without a current physician's order, and documentation was lacking in the MAR and TAR. The resident receiving nebulizer treatments was not monitored according to standards, with no staff present during treatment and no assessment of vital signs or breath sounds. Interviews revealed inconsistencies in monitoring practices, despite guidelines stating nurses should stay with residents during treatments.
The facility failed to follow physician-ordered fluid restrictions for two residents requiring dialysis. One resident received excessive fluids due to unclear instructions and lack of staff awareness, while another's meal tickets lacked fluid restriction information, leading to overconsumption. This indicates a deficiency in managing care for dialysis patients.
The facility failed to accurately reconcile controlled substances for four residents, leading to discrepancies between the Controlled Drug Disposition sheets and Medication Administration Records (MAR). Interviews with staff, including LPNs and the DON, revealed a lack of documentation for medications like Alprazolam, Tramadol, and Percocet, despite being dispensed. The DON and Consultant Pharmacist acknowledged the need for better education on documentation and reconciliation processes.
The facility failed to monitor medication side effects and efficacy for several residents, including those on psychotropic, antipsychotic, and hypoglycemic medications. This lack of monitoring was evident in the absence of documentation and care plan adherence, affecting residents with conditions such as diabetes, depression, and schizoaffective disorder. The consultant pharmacist and nursing staff acknowledged these deficiencies, indicating a systemic issue in medication management practices.
The facility failed to maintain sanitary storage of glucometers, secure medication storage rooms, and prevent residents from keeping medications at their bedside. A glucometer was improperly stored, the medication room door was left open, and a resident had an unsecured insulin pen accessible to others. Staff interviews revealed lapses in following protocols for medication storage and handling.
The facility did not follow their menu for the regular diet during a kitchen observation, affecting 117 residents. The menu specified 3 ounces of apple butter pork loin, but a lunch tray contained a slice weighing only 2.25 ounces. The Food Service Director stated that the cook should have pre-cut and weighed each slice to ensure it met the 3-ounce requirement, which was not done.
Two residents with severe cognitive impairments were served meals that did not meet the required pureed diet consistency, as observed during dining. The facility's policy mandates a smooth, pudding-like texture for pureed foods to ensure safe swallowing and minimize aspiration risk. However, meals served to these residents contained lumps and grainy textures, indicating non-compliance with the policy.
The facility failed to meet the dietary needs and preferences of three residents, leading to deficiencies in care. A resident with severe cognitive impairment did not receive a nutritional supplement, another with moderate impairment and multiple diagnoses did not receive a high-calorie pudding, and a third resident on a fortified food regimen did not receive the required fortified mashed potatoes. These oversights were confirmed by staff and highlight a failure to adhere to dietary plans.
A facility failed to maintain hospice documentation for a resident with severe cognitive impairment receiving hospice care. Despite an agreement requiring weekly discussions and medication reconciliation, the hospice nurse's progress notes were not kept in the facility, leading to a deficiency in documentation.
The facility failed to follow Enhanced Barrier Precautions (EBP) for several residents, with staff not consistently using gloves or performing hand hygiene. A CNA was observed touching surfaces without washing hands, and an LPN had long artificial nails, contrary to policy. Additionally, a resident's nebulizer mask was not stored properly, and EBP signage and supplies were inadequate.
The facility did not complete baseline care plans within the required 48-hour timeframe for three residents. The MDS Director and DON mistakenly believed the timeframe was 72 hours, leading to delays in finalizing care plans.
A resident with multiple health conditions did not receive a snack when the time between dinner and breakfast exceeded 14 hours, highlighting a deficiency in the facility's meal service. The resident, along with others, expressed dissatisfaction with the timing of meals and snacks, particularly noting late breakfast service and lack of timely coffee delivery.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain food service safety and sanitary conditions, impacting 187 of 196 residents. During a tour of the main kitchen, several deficiencies were observed. The handwashing station near the entry door had a dark substance on the grout above the sink. The exterior side walls of the Vulcan ovens were covered with a thick, burnt-yellow residue. In the Arctic walk-in refrigerator, brown debris was splattered on the tiles, and a yellow food substance was found on the floor. Additionally, a prepared food cart had salads with a sticker indicating dates that the Dietary Manager could not explain, requiring clarification from another staff member. Further observations revealed a crumpled ball of brown paper and a small, dark brown substance on the floor of the dry foods storage area. A dietary aide was seen preparing food without a beard covering. The dishwasher temperature was recorded at 170 degrees Fahrenheit, exceeding the manufacturer's recommended maximum of 140 degrees. A double handle stock pot had dark brown residue on its exterior and around the bolts securing the handles. These findings indicate a lack of adherence to professional standards for food storage, preparation, and service, potentially compromising food safety and sanitation.
Repeated Deficiencies in Resident Rights, Nutrition, Pharmacy, Meals, and Infection Control
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to implement an effective plan of action to correct identified quality deficiencies. These deficiencies were observed in areas such as Resident Rights / Exercise of Rights (F550), Nutrition / Hydration Status Maintenance (F692), Pharmacy Services / Procedures / Pharmacist / Record (F755), Frequency of Meals / Snacks at Bedtime (F809), and Infection Prevention and Control (F880). The facility had been previously cited for these deficiencies during a recertification survey with an exit date of 08/31/23, and they were identified again in the current survey. The repeated deficient practices have the potential to affect all 196 residents residing in the facility at the time of the survey. During the QAPI review, there was no evidence of an effective plan to address these cited deficiencies.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to treat residents with dignity during dining observations, as evidenced by staff referring to residents as 'feeders' and standing while feeding them. During observations, a registered nurse and certified nursing assistants were noted using the term 'feeder' when referring to residents who required assistance with meals. This terminology was used in the presence of other staff and residents, which is contrary to the facility's policy on dignity that emphasizes respectful communication and avoiding labels based on care needs. Additionally, staff were observed standing over residents while assisting them with meals, rather than sitting at eye level, which is necessary to maintain dignity and respect. Specific instances included staff standing while feeding residents with cognitive impairments and failing to promptly assist residents with their meals, leaving them waiting for extended periods. These actions were inconsistent with the facility's policy and the expectations for treating residents with dignity and respect.
Inaccurate MDS Assessments for Medications and Diagnoses
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in documenting medications and diagnoses. Resident #77 was admitted with multiple diagnoses, including nicotine dependence, and had a physician order for a nicotine patch. However, the resident was observed smoking, and the nicotine patch was not coded as a psychotropic medication in the MDS assessment. The Consultant Pharmacist was unaware of the resident's smoking and had not performed a Gradual Dose Reduction (GDR) as required. The MDS Director acknowledged the oversight but stated that a psychiatry consult had approved the concurrent use of the nicotine patch and smoking. Resident #167's clinical record showed a diagnosis of Schizoaffective Disorder, Bipolar Type, but the MDS assessment was incorrectly coded for Schizophrenia. The MDS Director and Coordinator admitted the error, noting that the diagnosis of Schizoaffective Disorder was always present in the resident's records, and the miscode occurred due to reliance on an incorrect diagnosis list. Resident #168's MDS assessment was inaccurately coded for anticoagulant use, despite no physician order for such medication. The resident was prescribed Aspirin as an antiplatelet, but the MDS Director mistakenly coded it as an anticoagulant. Additionally, the assessment failed to document the use of antibiotics, antidepressants, and hypoglycemic medications administered during the review period. The MDS Director attributed the errors to a 'click on error' and acknowledged the need for modification of the assessment.
Deficiencies in Care Plan Implementation for Psychotropic Medications and Antibiotic Therapy
Penalty
Summary
The facility failed to implement comprehensive care plans for residents on psychotropic medications and antibiotic therapy, leading to deficiencies in monitoring and addressing the medical, physical, mental, and psychosocial needs of the residents. For Resident #145, who was on Trazodone for depression, the care plan included goals to be free of drug-related complications and interventions to monitor side effects. However, there were no physician orders to monitor these side effects, and the staff was unaware of the need for such monitoring. Interviews with staff revealed a lack of understanding and communication regarding the necessity of monitoring side effects for psychotropic medications. Resident #198, who was on antibiotic therapy with Meropenem, had a care plan that included interventions for IV site monitoring and dressing changes. However, the MAR indicated that the required checks and dressing changes were not documented, and observations showed that the IV site was not properly maintained, with loose dressings and signs of drainage. The DON was aware that the antibiotic was discontinued but did not have information on why the IV catheter was still in place, indicating a lack of communication and follow-up with the physician. Other residents, such as Resident #73, #77, and #86, also had deficiencies in their care plans related to psychotropic medications. Resident #73 was on Sertraline without orders to monitor side effects, and Resident #77 was using a nicotine patch without proper monitoring for side effects or behavior changes. Resident #86, who was on Quetiapine for psychosis, did not have a care plan to monitor side effects of antipsychotic medications. These deficiencies highlight a systemic issue in the facility's approach to care planning and monitoring for residents on psychotropic medications.
Deficiencies in ADL Support and Care in LTC Facility
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in care. Resident #311, who has type 2 Diabetes and Dementia with a BIMS score indicating moderate to severe cognitive impairment, was observed with an untouched breakfast tray for 20 minutes without staff assistance. Despite needing partial to moderate assistance with eating, staff did not provide timely help, resulting in the resident consuming only 25% of the meal. Resident #40, diagnosed with multiple conditions including Cerebral Atherosclerosis and Dementia, was found to have inadequate oral care. Observations over several days showed the resident's mouth, lips, teeth, tongue, and gums were dry and cracked, with no water or Glycerin moisture sticks available at the bedside. Interviews with staff revealed a lack of adherence to the care plan, which required regular mouth care and hydration support, contributing to the resident's discomfort and potential dehydration. Resident #36, with severe cognitive impairment, expressed dissatisfaction with his grooming, specifically his facial hair, which was not maintained according to his preferences. Despite a care plan that included personal hygiene assistance, the resident's facial hair was unkempt, affecting his self-esteem. Additionally, Residents #144 and #59, both requiring assistance during dining, were observed struggling to eat without staff support, leading to food spillage and distress. These incidents highlight the facility's failure to provide necessary support for residents' ADLs, as outlined in their care plans.
Deficiency in Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for a resident, leading to a deficiency in care. The resident, who had a history of Atrial Fibrillation, Type I Diabetes Mellitus, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, and Chronic Kidney Disease, was observed with blood-tinged urine in the catheter tubing. Despite the resident's complaints of blood-tinged urine from the night of December 8th until the evening of December 10th, there was no documentation of urinary catheter care being performed during this period. Additionally, the urinary drainage bag was not changed, and the catheter was not irrigated, even though the resident reported these issues to the nursing staff. Observations revealed that the resident's urinary tubing had a blood-tinged color, and the urinary bag was improperly placed on the floor without privacy protection. Staff K, a Certified Nursing Assistant (CNA), was observed performing perineal care without changing gloves between tasks, which included touching various surfaces and the resident's personal items. This improper infection control practice was noted during the survey, and the urinary bag was placed on the floor, contrary to the facility's policy. Interviews with staff members, including CNAs and Registered Nurses (RNs), indicated a lack of communication and documentation regarding the resident's condition. Staff P, a CNA, stated that she frequently checks the urinary catheter but noted that there was no way to document cloudy or bloody urine in the facility's computer system. Staff N, an RN, admitted to not observing or documenting the resident's red-colored urine and not reviewing the care plan or MAR. The Director of Nursing (DON) confirmed that CNAs are responsible for urinary catheter care and should report any abnormalities to the nurse, who is then responsible for documenting these findings. However, this process was not followed, leading to the deficiency.
Failure to Calibrate Scales and Provide Timely Nutritional Supplements
Penalty
Summary
The facility failed to ensure accurate calibration of scales and timely provision of nutritional supplements for two residents, leading to significant weight loss. Resident #100, with chronic kidney disease and anemia, experienced a 17% weight loss over two months. Despite the dietary progress note indicating decreased meal intake and weight loss, the dietitian delayed increasing nutritional supplements, opting first to liberalize the diet. The supplements were only increased 40 days after the initial weight loss was identified. Resident #311, with type 2 diabetes, acute neurologic dysphagia, anemia, subdural hemorrhage, and dementia, experienced a 13.6% weight loss over less than six months. A possible weight discrepancy was noted, but no reweight was obtained, and the significant weight loss was not addressed after it was identified. The dietitian did not provide an explanation for the lack of action regarding the weight loss. Additionally, the facility's scales were not calibrated as required. Observations revealed that several scales and Hoyer lifts had outdated or missing calibration stickers. The Director of Plant Operations stated that an outside company was responsible for calibration, but there was no evidence of a recent inspection, and the director could not provide a contract with the company. This lack of calibration could have contributed to inaccurate weight measurements, impacting the residents' nutritional management.
Deficiencies in IV/PICC Line Management and Documentation
Penalty
Summary
The facility failed to obtain current specified physician's orders for the care and maintenance of IV/PICC lines for three residents, leading to deficiencies in the administration and documentation of IV therapy. Resident #308, who had a moderate cognitive impairment, was observed with a PICC line that lacked a date and time on the dressing, which was stained, peeling, and not securely attached. There were no physician's orders for the maintenance of the PICC line, and no documentation in the resident's care plan or medical records regarding the presence or care of the PICC line. Resident #185, with intact cognition, was admitted with a PICC line but lacked specific physician's orders for dressing changes and line flushing. Observations revealed the PICC line dressing was old, stained, and not securely attached, with no date or time noted. Interviews with staff indicated a lack of knowledge about the dressing change schedule, and there was no care plan or documentation of care performance for the PICC line in the resident's records. Resident #198, with mild cognitive impairment, had an IV catheter in place despite the completion of IV antibiotic therapy weeks prior. The dressing was loose, with reddish fluid drainage and a blood-like smell, and lacked date and nurse's initials. The resident was unaware of the reason for the continued presence of the IV catheter, and staff interviews revealed a lack of communication and documentation regarding the discontinuation of the IV catheter. The DON acknowledged the deficiencies in documentation and physician orders for the care and maintenance of the IV lines for all three residents.
Deficiencies in Oxygen and Nebulizer Therapy Administration
Penalty
Summary
The facility failed to obtain current physician's orders for oxygen therapy administration for a resident with chronic obstructive pulmonary disease, hypertension, and atherosclerotic heart disease. The resident was observed receiving continuous oxygen therapy at three to four liters via an oxygen concentrator without a current physician's order. Despite multiple observations over several days, no documentation was found in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) to indicate that the oxygen therapy was being administered as per a physician's order. Interviews with staff confirmed the absence of a current order, and a physician's order was only obtained after surveyor intervention. Additionally, the facility failed to monitor a resident receiving nebulizer treatments according to standards of care. The resident, who had a history of chronic obstructive pulmonary disease with acute exacerbation, acute respiratory failure with hypercapnia, atrial fibrillation, and sleep apnea, was observed receiving nebulizer treatment without proper monitoring. The resident's head was not elevated to the recommended semi-Fowler's position, and no staff nurse was present in the room during the treatment. The nurse did not assess the resident's breath sounds or take vital signs before, during, or after the treatment, and there was no documentation of the resident's toleration of the treatment or respiratory evaluation in the MAR. Interviews with staff revealed inconsistencies in the monitoring process for nebulizer treatments. While the unit manager and DON stated that nurses should stay with residents during nebulizer treatments to monitor changes, the observed practice did not align with this protocol. The respiratory therapist confirmed that it is recommended for nurses to stay with residents during the entire duration of nebulizer treatments to respond promptly to any breathing difficulties, such as bronchospasms, that may occur during the treatment.
Failure to Adhere to Fluid Restrictions for Dialysis Residents
Penalty
Summary
The facility failed to adhere to physician-ordered fluid restrictions for two residents requiring dialysis, leading to deficiencies in their care. Resident #123, who has End-Stage Renal Disease and receives dialysis three times a week, was observed to have received 829 ml of fluids in one meal, exceeding the prescribed daily fluid restriction of 1500 ml. The resident was not adequately educated on her fluid restrictions, and staff members, including a CNA and a Registered Nurse, were unclear about the specific fluid limits, leading to inconsistencies in the resident's care. Similarly, Resident #89, who has multiple diagnoses including Acute Kidney Failure and Chronic Kidney Disease, was subject to a daily fluid restriction of 1200 ml. However, observations revealed that the resident's meal tickets did not include information about fluid restrictions, and the dietary services provided fluids exceeding the prescribed limits. Staff members, including a CNA and the Kitchen Manager, were unaware of the resident's fluid restrictions, resulting in the resident receiving more fluids than allowed. The lack of communication and documentation regarding fluid restrictions for both residents highlights a systemic issue within the facility. The failure to provide clear instructions and ensure staff awareness of fluid restrictions led to the residents receiving excessive fluids, which could potentially impact their health. The facility's oversight in managing these restrictions indicates a deficiency in the care provided to residents requiring dialysis.
Controlled Substance Reconciliation Failures
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled substance medications for four residents, leading to discrepancies in medication administration records. For Resident #14, there was a lack of documentation for the administration of Alprazolam on specific dates, despite the medication being dispensed and removed from the controlled substance box. This discrepancy was confirmed during an interview with a Licensed Practical Nurse (LPN) and the South wing Unit Manager, who were unable to explain the inconsistencies. Resident #168 experienced similar issues with Tramadol HCl, where the Controlled Drug Disposition sheet indicated administration on certain dates, but the Medication Administration Record (MAR) lacked corresponding documentation. The LPN responsible for administering the medication could not account for the missing entries during a review with the Unit Manager. For Resident #186, the Controlled Drug Disposition sheets for Percocet showed discrepancies between the documented administration and the MAR. The LPN involved acknowledged signing the MAR but not the disposition sheet for certain dates. Additionally, Resident #201's records showed Tramadol HCl was dispensed without corresponding MAR documentation. The Director of Nursing and the Consultant Pharmacist recognized the need for improved education on controlled substance documentation and reconciliation after reviewing the discrepancies.
Failure to Monitor Medication Side Effects and Efficacy
Penalty
Summary
The facility failed to ensure proper monitoring of residents' medication regimens, particularly for psychotropic, antipsychotic, antiplatelet, and hypoglycemic medications. This was evidenced by the lack of written documentation of medication side effects, efficacy, and behavior monitoring for several residents. For instance, Resident #77, who had multiple diagnoses including Type 2 Diabetes Mellitus and Major Depressive Disorder, was not monitored for side effects of psychotropic medications or for signs of hypoglycemia and hyperglycemia as per the care plan. The consultant pharmacist acknowledged the lack of monitoring and the absence of a Gradual Dose Reduction (GDR) for the resident's medications. Resident #167, diagnosed with Schizoaffective Disorder and other conditions, was also not monitored for side effects of psychotropic, antianxiety, and opioid medications. Despite care plan interventions requiring such monitoring, the December 2024 Medication Administration Record (MAR) showed no evidence of it. The consultant pharmacist had previously recommended tracking adverse effects, but this was not implemented. An attempt to interview the resident revealed agitation and cursing, indicating potential unmanaged symptoms. Other residents, such as Resident #73 and Resident #145, were similarly affected by the facility's failure to monitor medication side effects and behaviors. Resident #73, on Sertraline for depression, had no orders for monitoring side effects, and the Director of Nursing confirmed the lack of monitoring. Resident #145, on Trazodone for depression, also lacked monitoring orders, and the consultant pharmacist admitted to missing this requirement. These deficiencies highlight a systemic issue in the facility's medication management practices, affecting the well-being of multiple residents.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to store residents' glucometers in a sanitary manner, as observed in the North wing medication storage room. A glucometer was found on top of the medication cart without being contained in a plastic wrap, directly touching sterile lancets. This was confirmed by a Registered Nurse who acknowledged the requirement for glucometers to be wrapped but did not provide an explanation for the oversight. Additionally, the facility lacked a specific policy for glucometer storage, although the Director of Nursing stated that nurses are educated on proper storage during orientation. The North wing medication storage room door was found halfway open without staff supervision, allowing potential unauthorized access to medications. The key to the storage room was also left hanging outside on a desk, further compromising security. This situation persisted for at least ten minutes before being addressed by a staff member. The Director of Nursing confirmed that there is no specific policy for glucometer storage but emphasized that staff are educated on proper procedures. Resident #407 had an unsecured insulin pen on her nightstand, accessible to others. The resident, who has Type 2 Diabetes Mellitus and other conditions, stated she brought the pen from home and believed it was empty. Staff interviews revealed that medications brought from home should be collected and returned to family members, but this protocol was not followed in this case. The Director of Nursing acknowledged the oversight but noted that staff cannot search through residents' belongings.
Menu Adherence Failure in Kitchen Observation
Penalty
Summary
The facility failed to adhere to their menu for the regular diet during an observation in the main kitchen, which could potentially affect 117 residents on a regular diet. The facility's fall/winter 2024 diet guide specified that the regular diet should include 3 ounces of apple butter pork loin. However, during an observation, a lunch tray was found to contain a pre-sliced piece of pork loin weighing only 2.25 ounces, which did not meet the specified menu requirement. An interview with the Food Service Director revealed that the cook was responsible for pre-cutting and weighing each slice of pork to ensure it met the 3-ounce requirement, which was not done in this instance.
Failure to Provide Proper Pureed Diet Consistency
Penalty
Summary
The facility failed to provide food in a form designed to meet individual needs for residents on a pureed diet, specifically affecting two residents observed during dining. Resident #22, who has severe cognitive impairment due to cerebral atherosclerosis and hypertension, was observed eating a breakfast meal that included pureed pancakes with lumps, contrary to the facility's policy requiring a smooth, pudding-like consistency for pureed diets. Similarly, Resident #48, diagnosed with dementia and depressive disorder, was observed consuming meals that did not meet the required pureed consistency. During breakfast, the pureed breakfast meat and pancakes were noted to be grainy and lumpy. At lunch, the pureed turkey was also observed to be lumpy. The facility's policy, which aims to promote safe swallowing and minimize aspiration risk, was not adhered to, as confirmed by the speech therapist who stated that pureed foods should have a cohesive, smooth texture without particles or lumps.
Failure to Accommodate Dietary Needs and Preferences
Penalty
Summary
The facility failed to accommodate the dietary needs and preferences of three residents, leading to deficiencies in their care. Resident #32, who has severe cognitive impairment and is diagnosed with protein-calorie malnutrition and dementia, did not receive a Mighty Shake nutritional supplement as indicated on their lunch tray. Despite the presence of staff members responsible for ensuring the correct food items and supplements are provided, the supplement was missing from the tray. Resident #100, with moderate cognitive impairment and multiple diagnoses including chronic kidney disease and anemia, did not receive a high-calorie pudding as per their dietary plan. The resident expressed dissatisfaction with the missing item, which was confirmed by multiple staff members, including the Certified Dietary Manager and Registered Dieticians, who acknowledged the oversight. The resident's care plan specifically included fortified foods to address their nutritional needs, yet the high-calorie pudding was absent from their meal tray. Resident #144, with severe cognitive impairment and a diagnosis of epilepsy and hypothyroidism, was on a fortified food regimen. However, during meal observations, the fortified mashed potatoes, which were supposed to be part of their diet, were not included on their tray. The Food Director confirmed the absence of the fortified food item, which was supposed to be provided according to the resident's dietary plan. These incidents highlight the facility's failure to adhere to its policy of accommodating resident food preferences and dietary needs.
Failure to Maintain Hospice Documentation
Penalty
Summary
The facility failed to meet professional standards by not ensuring that hospice documentation was readily available for a resident receiving hospice care. The facility had an agreement with a hospice company, which required the facility to maintain medical records, including progress notes and clinical notes for each hospice patient. However, during a review, it was found that the hospice binder for a resident did not contain any progress notes from the hospice nurse, despite the resident being on hospice care since May 2024 and having had ten visitations by the hospice nurse from June to December 2024. The resident in question was admitted with a diagnosis of age-related physical debility and had a severe cognitive impairment, as indicated by a BIMS score of 6. The facility's agreement with the hospice company also required weekly discussions between the hospice nurse and the facility's staff, as well as medication reconciliation at each visit. Despite these requirements, the RN Manager acknowledged that the hospice nurse's progress notes were sent to the hospice company and not kept in the facility, leading to the deficiency in maintaining proper documentation.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to the Enhanced Barrier Precautions (EBP) guidelines for four residents, leading to multiple instances of improper infection control practices. For Resident #26, staff members did not consistently use gloves or perform hand hygiene when providing care, such as changing socks and handling bed controls. Staff J, a CNA, was observed touching various surfaces and equipment without washing hands between tasks, increasing the risk of cross-contamination. Similarly, for Resident #139, Staff J did not clean the Hoyer lift after use, further compromising infection control measures. Resident #465's care was also compromised as staff did not wear the required personal protective equipment (PPE) while providing care, despite the presence of an EBP sign. This oversight indicates a lack of compliance with established guidelines meant to protect both residents and staff from potential infections. Additionally, Resident #460's room lacked proper EBP signage and supplies, which were observed to be located several doors away, indicating a systemic issue in maintaining infection control protocols. The facility also failed to ensure proper hygiene practices concerning fingernail length and cleanliness among staff. Staff U, an LPN, was observed with long artificial nails, which are known to harbor bacteria and compromise hand hygiene. Despite the facility's policy against artificial nails, both Staff U and Staff V, a Registered Nurse/Unit Manager, were found with long nails, indicating a disregard for infection control policies. Furthermore, the nebulizer mask for Resident #507 was not stored in a sanitary manner, as it was left uncovered on a bedside table, contrary to the facility's policy on respiratory equipment maintenance.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within the required 48-hour timeframe for three of five sampled residents. For Resident #36, the baseline care plan was initiated on November 1, 2024, but not completed until November 5, 2024. Similarly, Resident #508's care plan was started on November 29, 2024, and completed on December 2, 2024. Resident #189's care plan was initiated on October 18, 2024, and completed on October 21, 2024. An interview with the MDS Director revealed a misunderstanding of the required timeframe, as she believed the completion time was 72 hours instead of the mandated 48 hours. This misunderstanding was confirmed by the Director of Nurses, who also stated the incorrect timeframe.
Failure to Provide Timely Snacks and Meals
Penalty
Summary
The facility failed to provide a nourishing snack to residents when the time lapse between dinner and breakfast exceeded 14 hours. This deficiency was observed for a resident who did not receive a snack the previous evening, resulting in a time lapse of 14 hours and 34 minutes between dinner and breakfast. The resident, who has a diagnosis of Cancer, Anemia, Orthostatic Hypotension, Thyroid Disorder, and Depression, expressed dissatisfaction with the timing of meals and snacks, particularly noting that breakfast was served too late and coffee was not provided at the desired time. During a resident council meeting, multiple residents voiced concerns about difficulties in obtaining snacks at preferred times, indicating a broader issue within the facility's kitchen services. The resident in question, who has moderate cognitive impairment, specifically mentioned that breakfast trays are typically delivered around 9:30 AM, which he finds unsatisfactory. This situation highlights the facility's failure to meet the nutritional needs and preferences of its residents, potentially affecting 22 of 24 residents on oral diets in the same wing.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 347 citations issued within 25 miles in the last 12 months — including the 4 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 Fort Lauderdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wilton Manors Healthcare & Rehabilitation Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Ft Lauderdale Health & Rehabilitation Center | 2.1 mi | ★★★★★ | 19 | 0 |
| Savoy At Fort Lauderdale Rehabilitation And Nursin | 2.1 mi | ★★★★★ | 0 | 0 |
| Broward Nursing & Rehabilitation Center | 3.9 mi | ★★★★★ | 0 | 0 |
| Aviata At The Sea - Harbor Beach | 4 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pearl At Fort Lauderdale Rehabilitation And Nursin.
100% money-back within 48 hours.
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.