Above 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 St Johns Nursing Center during CMS and state inspections, most recent first.
Surveyors identified widespread unsanitary conditions and improper food handling in the kitchen and storage areas, potentially affecting 154 residents. Observations included open and improperly placed garbage bins, sanitizer buckets with no active sanitizing agent, and visibly soiled food containers such as a banana bin with debris and hair. Expired and visibly spoiled items were found in the walk‑in refrigerator, including ricotta cheese, chocolate frosting, pureed pumpkin, and ice cream toppings, along with undated leftover beef and a case of Mighty Shakes stored unfrozen despite "Keep Frozen" labeling. Kitchen equipment such as the juice machine, tilt skillet, grill, oven, toaster, and microwave had accumulated food residue and grease, while muffin pans and shelving showed rust‑colored and stuck‑on debris. In the dry storage area, cans had white granules, a dented can was not segregated, floors and shelves were dirty, pasta was on the floor, and a slicer stored with other pans had a dead roach on it, with disinfectant spray stored next to food equipment. Personal instant coffee was also stored in the food production area, and bulk ingredient containers were sticky and soiled on the exterior.
A resident admitted after right knee surgery with a history of AKI, A-fib, and HTN had sacral redness/rashes and a Stage I pressure injury documented on admission, but staff failed to complete and record the required weekly monitoring and measurements of this sacral skin condition. Initial nursing notes described sacral redness/rashes present on admission, yet subsequent documentation focused only on the right knee surgical site. CNAs and RNs reported performing skin assessments and believed that any changes were reported and that weekly assessments occurred, but the RN stated she did not monitor or measure the sacral area after admission, assuming the wound care nurse was responsible. The wound care nurse, in turn, stated she did not monitor or document the sacral area, believing the staff nurses were doing so. Despite a care plan directing weekly monitoring, measuring, and documentation of the sacral area until healed, no such weekly documentation was found in the record.
The facility failed to maintain dignity during mealtimes, referring to residents needing assistance as 'feeders' and delaying meal service. A resident waited 35 minutes for a meal, while another with severe mental impairment had a meal tray left unattended for 10 minutes. Staff stood over a resident with moderate cognitive impairment while feeding, rather than sitting at eye level.
The facility failed to ensure that call lights were within reach for three residents, despite policy requirements. A resident with severe cognitive impairment and two residents with moderate cognitive impairment and upper extremity impairments were observed with call lights wrapped around bed rails, making them inaccessible. Staff interviews confirmed awareness of the policy, yet the deficiency persisted.
A resident was transferred to a nursing home from an ALF due to renovations and financial reasons, with an expected return in two months. However, after three months, the resident had not been informed about his return and felt his concerns were ignored. Facility staff provided inconsistent information about the necessity of the nursing home stay, and the resident expressed dissatisfaction with the lack of communication and services received. The Administrator acknowledged the resident's complaints and facilitated his return to the ALF after surveyor intervention.
A resident with severe cognitive impairment and physical limitations was observed with overgrown facial hair, indicating a failure by the facility to provide necessary grooming assistance. Despite the CNA's awareness of the issue, no action was taken initially. The facial hair was later removed, but staff interviews did not reveal who provided the care, highlighting deficiencies in care provision and documentation.
A facility failed to follow physician orders for a resident's urinary care, leading to a deficiency. The resident, with multiple health issues, was to receive Foley catheter care every shift, but nursing notes lacked documentation of this care. Observations showed reddish tinged urine with sediments in the tubing and drainage bag, and the bag often lacked a privacy cover. An LPN was aware of procedures for red-colored urine but did not document or notify the physician, contributing to the deficiency.
A facility failed to follow fluid restriction orders for a dialysis resident, leading to excessive fluid intake. The resident, with End Stage Renal Disease, was supposed to have a daily fluid limit of 1200 ml, but records showed nursing staff often exceeded this limit. Observations revealed a lack of awareness among staff about the fluid restriction, and inconsistent documentation further complicated adherence to the physician's orders.
A resident's personal items, including cash and a gate card, went missing in an LTC facility. Despite communication with the social worker and photographic evidence, the facility failed to follow its policy on handling valuables, resulting in a deficiency. The Director of Social Services and the DON were not informed, and no grievance was filed. The Administrator was unaware of the issue until the survey.
The facility failed to secure medications and treatment carts, leaving them unattended and accessible. An LPN left medication cups on a cart, and a resident had pills left at her bedside without being assessed for self-administration. A wound care nurse left a treatment cart unlocked, and a medication cart was found unattended. Staff acknowledged these lapses, which violated facility policies.
The facility failed to honor the food preferences of several residents during a lunch meal. A resident with GERD was served a different meal than indicated on the meal ticket. Another resident with heart and kidney issues received only mashed potatoes instead of the specified sandwich and tots. A third resident received a beef sandwich instead of a peanut butter and jelly sandwich. Staff interviews confirmed these discrepancies, and the DON acknowledged the issues.
The facility failed to maintain food safety and proper portion control in the kitchen. Observations revealed the Food Service Director without a facial hair covering, a dirty rag on the counter, and several food items past their used-by dates. Additionally, a meal was served with incorrect portion size, weighing only 2 ounces instead of the required 3 ounces. These deficiencies highlight issues in food service safety and sanitary conditions.
A facility failed to disinfect a vital signs machine between uses for multiple residents and did not follow droplet precaution protocols for a COVID-19 positive resident. A CNA used the machine on several residents without cleaning it and did not consistently perform hand hygiene. Another CNA entered a COVID-19 isolation room without proper PPE, touching surfaces and the resident's items with bare hands, contrary to the facility's infection control guidelines.
Widespread Unsanitary Food Storage, Preparation, and Equipment Conditions in Kitchen
Penalty
Summary
The deficiency involves the facility’s failure to procure, store, prepare, and serve food in a safe and sanitary manner in the kitchen and food storage areas, with the potential to affect 154 residents. During a kitchen tour with the Kitchen Supervisor, Kitchen Manager, and Director of Food and Nutrition Services, surveyors observed an open tall gray garbage bin near the Vulcan stove, with no garbage bin near the handwashing area. Two red buckets identified as sanitizing solution were tested and showed no active quaternary ammonium sanitizer, as the test strips remained yellow instead of turning green-blue. A plastic bin holding bananas contained small round beige debris, a piece of white paper, brown/black debris, and a hair. In the pot washing room, a garbage bin was located very close to the mixer, which should be maintained in a clean area away from garbage. Three AC vents above the tray line had caked-on dark gray matter extending onto the surrounding ceiling. Multiple issues were identified in the walk-in refrigerator and other cold storage. Ricotta cheese with a manufacturer’s expiration date of 02/01/26 had expired and had clusters of dark black-green spots on the exterior top of the container. An open 12‑pound container of chocolate frosting with an expiration date of 01/31/26 was also expired and had thick green substance and clusters of green matter on the exterior grooves. A plastic container of pureed pumpkin labeled as prepared on 02/04/26 with a use‑by date of 02/11/26 had visible spherical matter with spore-like projections on the top layer. A plastic container with a piece of beef in the walk‑in refrigerator had no date, and the Kitchen Manager did not know how long it had been stored. A case of Mighty Shakes labeled “Keep Frozen” and dated 01/31/26 was found in a reach‑in refrigerator in an unfrozen state, and neither the Director of Food and Nutrition Services nor the Kitchen Supervisor knew how long it had been there. Two plastic containers of ice cream toppings with handwritten expiration dates of 10/20/25 were expired, and one opened container of beige, crunchy topping remained in storage. Additional unsanitary conditions and improper storage were observed throughout the kitchen and dry storage areas. The juice machine had a buildup of pink and yellow‑orange residue. The Vulcan tilt skillet handle and oven temperature knob had thick yellow‑brown residue in grooves, with particles on the skillet surface; the adjacent grill had yellow and yellow‑brown food remnants on the cooking surface, borders, and backsplash, and food remnants were present on the counter between the counter and grill. The Vulcan oven had dried yellow‑brown liquid on the ledge, brown residue on the interior door, and black buildup on the oven floor, despite being reported as cleaned weekly. In the dry goods room, cans had white granules on top, one can of evaporated milk was dented and not separated, the floor had stuck‑on brown‑black residue, pasta was on the floor near shelving wheels, and shelves showed yellow‑brown stuck‑on residue and dried drippings. Muffin pans had rust‑colored debris, white residue, and food particles. A slicing machine stored on a shelf had a dead roach on it, with a bottle of disinfectant spray stored next to it. Rubbermaid containers of sugar, lentils, and dried peas were sticky with yellow and brown residue on the exterior; the top of a rolling toaster had dried dark brown greasy spills; the interior of an Amana microwave had yellow‑brown buildup; and a plastic bag of personal instant coffee was stored on a lower shelf in the food production area.
Failure to Document Ongoing Assessment of Sacral Skin Condition
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy requiring evaluation and documentation of identified skin changes in the weekly skin check section of the electronic medical record. The facility’s Wound Prevention, Skin Observation policy stated that nurses must evaluate and document identified changes weekly. Resident #1, admitted after right knee surgery with a history of Vancomycin-induced acute kidney injury, atrial fibrillation, and hypertension, had a documented Stage I pressure ulcer or injury on the admission MDS and nursing notes indicating sacral redness/rashes present on admission. After two initial nursing progress notes describing the sacral redness/rashes with no signs of infection, there were no further nursing progress notes addressing this sacral skin condition, despite ongoing daily skin assessments that focused on the right knee surgical site. Interviews with staff revealed inconsistent understanding of responsibility for monitoring and documenting the sacral area. A CNA reported that she performs ongoing skin checks during daily care and reports changes to nurses, and an RN stated that she performs head-to-toe assessments on admission, documents findings, and notifies the physician. The RN also stated that weekly skin assessments were performed for the resident’s sacral redness but acknowledged she did not monitor or measure the area after admission, believing the wound care nurse was responsible. The wound care nurse reported seeing the sacral redness on admission, with a cream ordered and applied and a turning schedule in place, but stated she did not monitor the sacral area and only monitored and documented the right knee surgical site, assuming the staff nurses were monitoring and documenting the sacral redness/rashes. The resident’s care plan required weekly monitoring, measuring, and documentation of the sacral wound status until healed, but record review showed no such weekly documentation in the nursing progress notes, and the ADON confirmed that, despite staff training, the nurses had not documented according to policy.
Undignified Mealtime Practices and Delayed Meal Service
Penalty
Summary
The facility failed to treat residents in a dignified manner during mealtime observations and did not provide adequate grooming for one resident. During mealtime on the 2nd floor South unit, staff members referred to residents as 'feeders,' which is considered undignified. Resident #140 experienced a delay in receiving her lunch tray, waiting approximately 35 minutes after her roommate had finished eating. Additionally, Resident #75, who has moderate cognitive impairment, was fed while staff stood over him, rather than sitting at eye level, which is the recommended practice for maintaining dignity. Resident #100, who has severe mental impairment and primarily receives nutrition through a PEG tube, was also referred to as a 'feeder' by staff. His dinner tray was left in front of him for 10 minutes without assistance, despite his need for help with eating. These observations indicate a pattern of undignified treatment and inadequate assistance during mealtimes for residents requiring help, as well as a lack of timely meal service for some residents.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that residents' call devices were within reach, affecting three residents. The facility's policy mandates that call bells be accessible to facilitate care and enhance safety. However, during observations, it was noted that the call light cords for Residents #85, #153, and #51 were wrapped around bed rails, leaving the call buttons dangling and out of reach. This was confirmed through interviews with staff and photographic evidence. Resident #85, who has severe cognitive impairment and is dependent on staff for activities of daily living, was observed unable to reach his call light. Despite having no upper extremity impairment, the call light was not accessible, and the resident could not indicate its location. Similarly, Resident #153, with moderate cognitive impairment and upper extremity impairment on one side, reported that his call light was often unreachable. Observations confirmed that his call light was not within reach, and he expressed difficulty in accessing it. Resident #51, also with moderate cognitive impairment and upper extremity impairment, stated that he could never find his call light and resorted to using his cell phone to contact his daughter for assistance. Observations showed that his call light was not accessible, corroborating his statement. Interviews with various staff members, including the Nurse Manager and CNAs, revealed an awareness of the policy to keep call lights within reach, yet the deficiency persisted, indicating a lapse in adherence to the facility's procedures.
Failure to Honor Resident's Right to Self-Determination
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not facilitating his return to an assisted living facility (ALF) after his temporary stay at the nursing home. The resident, who was cognitively intact with a BIMS score of 15/15, was initially transferred to the nursing home due to renovations at his ALF apartment and was expected to return in two months. However, three months later, the resident had not received any communication regarding his return and felt his concerns were ignored. Interviews with facility staff revealed inconsistencies and lack of documentation regarding the resident's admission to the nursing home. The Social Services Director and a Social Worker indicated that the resident was transferred due to financial reasons and pending Medicaid approval, but neither could provide documentation supporting the necessity of the nursing home stay. The Director of Nursing and a Resident Navigator provided conflicting information about the resident's need for nursing home care, with the DON unaware of a physician's assessment indicating the resident did not require such services. The resident expressed dissatisfaction with his stay, stating he had not received rehabilitation services and was only given medications. He was concerned about the financial implications of his stay and felt restricted in handling his personal affairs compared to his previous autonomy at the ALF. The Business Office Manager confirmed the resident's Medicaid application was approved, but the delay resulted in unexpected costs. The facility's Administrator acknowledged the resident's complaints and the lack of communication regarding his return to the ALF, which was eventually facilitated after surveyor intervention.
Failure to Assist Resident with Personal Grooming
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for a resident, identified as Resident #139, who was unable to perform self-care due to severe cognitive impairment and physical limitations following a cerebrovascular aneurysm. The resident required total assistance for most ADLs, including personal grooming. On a specific date, the resident was observed with overgrown facial hair, indicating a lack of grooming assistance. Despite being aware of the resident's condition, the assigned Certified Nursing Assistant (CNA) did not take action to address the overgrown facial hair. Subsequent observations revealed that the resident's facial hair was eventually removed, but there was no documentation or staff acknowledgment of who provided the grooming care. Interviews with the staff, including the Unit Manager, failed to identify who attended to the resident's grooming needs. This lack of documentation and accountability highlights a deficiency in the facility's care provision and record-keeping practices, as the resident's grooming needs were not consistently met or recorded.
Failure to Follow Physician Orders for Urinary Care
Penalty
Summary
The facility failed to follow physician orders for urinary care for a resident with an indwelling catheter, leading to a deficiency in care. The resident, who had multiple diagnoses including chronic urinary retention and obstructive uropathy, was supposed to receive Foley catheter care every shift as per physician orders. However, nursing notes from multiple shifts lacked documentation of catheter care, and observations revealed that the resident's urinary tubing and drainage bag contained reddish tinged urine with sediments, indicating a potential urinary tract infection. Additionally, the urinary drainage bag was observed without a privacy cover on several occasions. Interviews with staff revealed that the LPN responsible for the resident's care was aware of the procedures to follow if red-colored urine was observed, including documenting the findings and notifying the physician. Despite this, there was no documentation of such actions being taken in the nursing notes. The lack of proper catheter care and documentation, as well as the failure to notify the physician of changes in the resident's urine, contributed to the deficiency in care for the resident.
Failure to Adhere to Fluid Restriction Orders for Dialysis Resident
Penalty
Summary
The facility failed to adhere to physician orders for fluid restriction for a resident undergoing dialysis, identified as Resident #42. The resident, who has diagnoses including End Stage Renal Disease, Anxiety Disorder, Anemia, and Hypertension, was supposed to have a daily fluid intake limited to 1200 ml, divided between nursing and dietary departments. However, records revealed that the nursing staff frequently exceeded the prescribed fluid limit, providing amounts ranging from 360 ml to 960 ml, which surpassed the 480 ml limit set for nursing. Additionally, the dietary department was providing an average of 780 ml daily, which also exceeded the intended 720 ml. This discrepancy in fluid management was further compounded by the lack of consistent documentation and communication between the nursing and dietary departments regarding the resident's actual fluid consumption. Observations and interviews highlighted a lack of awareness and adherence to the fluid restriction protocol among staff. The resident was observed with a water pitcher at her bedside, and when questioned, she indicated a lack of understanding of her fluid restrictions. Interviews with staff members revealed inconsistencies in their understanding and execution of the fluid restriction orders. The CNA responsible for the resident's care mentioned general practices for managing fluid intake but did not demonstrate a clear understanding of the specific fluid restriction order. The regional dietician acknowledged the dietary department's role in providing fluids but noted that they did not maintain records of the resident's total fluid consumption, relying instead on nursing documentation, which was inconsistent and incomplete.
Failure to Address Missing Personal Items and Clothing
Penalty
Summary
The facility failed to address social services responsibilities regarding missing personal items and clothing for a resident, leading to a deficiency. The resident, who had a history of multiple medical conditions including diabetes, anxiety disorder, and hypertension, was admitted to the facility. The resident's son reported missing personal items, including cash and a gate card, which were not addressed by the facility staff. Despite photographic evidence and communication with the facility's social worker, the missing items were not located or resolved. The facility's policy on handling valuables was not followed, as there was no documentation of efforts to locate the missing items or to inform pertinent staff members. The social worker, Staff V, acknowledged receiving emails from the resident's family regarding the missing items but did not document any further actions or communication with the family. The Director of Social Services and the Director of Nursing were not informed of the missing items, and no grievance was filed as per the facility's protocol. The facility's storage areas for personal items were not regularly checked, and there was no master inventory list for residents' belongings. The Administrator was unaware of the missing items until the survey. The lack of communication and documentation, along with the failure to follow established procedures, contributed to the deficiency in addressing the resident's missing personal items and clothing.
Medication and Treatment Cart Security Lapses
Penalty
Summary
The facility failed to secure dispensed medications, which were left unattended on a medication cart and at a resident's bedside. During an initial tour, a Licensed Practical Nurse (LPN) was observed leaving two small medication cups on top of a locked medication cart. The LPN confirmed that the cups contained medications for a resident who had refused them, and she intended to administer them later. This action was against the facility's policy, which requires that dispensed medications be discarded if refused and not stored for later administration. Additionally, a resident was found with a small medication cup containing four unidentified pills on her over-bed-side table. The resident stated that the nurse left the medications for her to take, which was a recurring practice. The resident had not been evaluated for self-administration of medications, as required by the facility's policy. The policy mandates that medications should not be left at the bedside unless the resident is assessed and approved for self-administration, with medications stored in a locked cabinet or drawer. The facility also failed to secure a treatment cart during a wound care observation. A wound care nurse left the treatment cart unlocked and unattended in the hallway while attending to a resident. The cart contained ointments, creams, and other supplies, posing a risk of unauthorized access. Furthermore, a medication cart on the South Wing was observed unlocked and unattended, accessible to residents, staff, and visitors. Staff members acknowledged these lapses, which were contrary to the facility's policy requiring medication carts to be locked when not attended.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of several residents during a lunch meal, as observed in the cases of four residents. Resident #14, who has a diagnosis of Gastroesophageal Reflux Disease (GERD) and moderate cognitive impairment, was served a mechanical soft diet of chicken chunks and rice, despite the meal ticket indicating chopped chicken with rice. Staff interviews confirmed the discrepancy between the meal served and the resident's preferences. Resident #151, with diagnoses including Acute Systolic Heart Failure, Atherosclerotic Heart Disease, and Chronic Kidney Disease, was supposed to receive an Italian Beef Sandwich with potato tots according to the meal ticket. However, the resident was only served mashed potatoes and gravy, with no meat or bread. The resident expressed dissatisfaction with the repetitive and unappealing meals, and staff interviews corroborated the inconsistency between the meal ticket and the food served. Resident #133, who has intact cognition and diagnoses including Metabolic Encephalopathy and Vitamin Deficiency, was supposed to receive a peanut butter and jelly sandwich but was instead served a beef sandwich with tater tots, fruit, and soup. The resident expressed dissatisfaction with the taste and quality of the food, noting that the sandwich was dry and tough. Staff interviews confirmed the discrepancy between the meal ticket and the food served. The Director of Nursing acknowledged the discrepancies in meal service for these residents.
Food Safety and Portion Control Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety and sanitary conditions, as observed during a survey of the main kitchen. The Food Service Director was noted to be without a facial hair covering in the food production area, and a dirty used rag was left on the food production counter instead of being placed in a sanitation bucket. Additionally, one of the three lights under the hood was not functioning, and a private plastic drinking cup was found under the food production area. Several food items in the walk-in refrigerator were past their used-by dates, including cooked pork, [NAME] sauce, marinara sauce, cooked eggs, and raw fish and chicken. Notably, a container of cream of broccoli soup had an unusually long used-by date, which the Food Service Director could not explain. During a tray line observation, the facility failed to serve the correct portion size as per the menu for a Regular diet. A large tray of pre-sliced pork pieces was noted, and the Food Service Director plated a meal with sliced pork and salsa sauce that weighed only 2 ounces instead of the required 3 ounces. An interview with a cook revealed that pork pieces were pre-sliced to 4 ounces each, indicating a discrepancy in portioning. These observations highlight the facility's failure to maintain food safety and proper portion control, potentially leading to foodborne illnesses and inadequate nutrition for residents.
Infection Control Deficiencies in Equipment Disinfection and PPE Use
Penalty
Summary
The facility failed to properly disinfect a vital signs machine between resident uses, as observed with three residents. A Certified Nursing Assistant (CNA), identified as Staff O, was seen using a vital signs machine on multiple residents without cleaning or disinfecting it between uses. This included not sanitizing the machine after use with Resident #137, Resident #428, and another resident. Staff O also failed to perform hand hygiene consistently between resident interactions, which is a critical step in preventing the transmission of infections. Additionally, the facility did not adhere to droplet precaution protocols for a resident diagnosed with COVID-19. Resident #375, who was on droplet isolation due to a positive COVID-19 diagnosis, was visited by Staff A, a CNA, who entered the room without wearing the required personal protective equipment (PPE) such as a gown and gloves. Staff A also failed to sanitize her hands before entering the room and touched various surfaces and the resident's items with bare hands, which could potentially lead to the spread of infection. The facility's infection control policies, as outlined in their guidelines, were not followed in these instances. The guidelines specify the need for proper hand hygiene, the use of PPE, and the disinfection of equipment between uses to prevent the transmission of infections. The failure to adhere to these protocols was confirmed through interviews with staff members, who acknowledged the requirements for PPE and hand hygiene in isolation situations.
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Illustrative
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lauderdale Lakes
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palms Care Center And Rehab | 1.1 mi | ★★★★★ | 1 | 0 |
| Life Care Center At Inverrary | 1.7 mi | ★★★★★ | 10 | 0 |
| Nspire Healthcare Lauderhill | 1.8 mi | ★★★★★ | 0 | 0 |
| Plantation Nursing & Rehabilitation Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Wilton Manors Healthcare & Rehabilitation Center | 3 mi | ★★★★★ | 0 | 0 |
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