Coral Springs Rehab & Healthcare

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and facility document and policy review, the facility failed to follow the planned menu. Specifically, the facility did not follow the recipe and served the incorrect portion size for the regular and pureed diets for the lunch meal on 12/03/2025. This failure had the potential to affect 151 residents who received meals from the kitchen.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, facility document and policy review, and the United States Food and Drug Administration (FDA) guidelines the facility failed to store, distribute, and serve food in accordance with food safety standards. Specifically, the facility failed to ensure staff dated prepared food items held for storage, stored potentially hazardous food below ready-to-eat food and failed to ensure freezer items were dated and labelled and in closed containers. Additionally, the facility failed to ensure that the dish machine was dispensing appropriate sanitizer per manufacturer guidelines and food was at the appropriate temperature while being held on a hot steam table for service.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and facility policy review, the facility failed to ensure medication and treatment carts were locked when not within line of sight for 5 (one treatment cart on the F and G Halls, one medication cart on the B Hall, one medication cart on the D Hall, one medication cart on the G Hall, and one medication cart on the F Hall) of 9 medication and treatment carts observed in the facility.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview, record review, and facility policy review, the facility failed to respect a resident's right to refuse a medication for 1 (Resident #181) of 7 sampled residents reviewed for choices.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure that a resident's bed was maintained in safe operating condition for 1 (Resident #142) of 7 residents reviewed for environment.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on facility policy review, record review, facility document review, and interview, the facility failed to report allegations of abuse or injuries of unknown origin to the state survey agency within required timeframes, which affected 3 (Residents #67, #178, and #185) of 7 residents reviewed for abuse or injuries of unknown origin.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on facility policy review, record review, facility document review, and interview, the facility failed to thoroughly investigate an allegation of staff-to-resident physical and verbal abuse for 1 (Resident #185) of 7 residents reviewed for abuse or injuries of unknown origin.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on facility policy review, record review, facility document review, and interview the facility failed to ensure that residents were free from accident hazards related to the inappropriate use of a mechanical lift, which affected 1 (Resident #184) of 10 residents reviewed for accidents.

Inspectors wroteBased on record review and interview, it was determined that for one (R159) out of seven residents reviewed for hospitalizations, the facility failed to ensure that R159 received care/treatment in accordance with professional standards of practice. The facility failed to monitor bowel movements resulting in a hospitalization requiring fecal disimpaction.

Inspectors wroteBased on interviews, record review and review of other documents as indicated, it was determined that for one (R157) out of six residents reviewed for hospitalization, the facility failed to provide the necessary treatment consistent with professional standards of practice, to provide pain assessments and pain medication prior to the daily wound care for R157's extensive left lower leg wounds. The result of that incomplete pain assessment and medication administration resulted in harm. R157 experienced pain when her wound care was completed.

Inspectors wrote2. 11/4/24 9:00 AM - During an interview, R78 stated that the lunch and dinner meals on Sunday 11/3/24 were both late in delivery and did not have reasonable portions or selection of foods. 11/4/24 3:15 PM - An email request was made to E1 (NHA) to provide the kitchen staff time cards for 11/2/24 and 11/3/24. 11/4/24 - A review of the facility dietary time cards for 11/3/24 revealed that no member in the facility's food service department possessed a valid Food Protection Manager certificate from an Accredited Food Safety Program on 11/3/24 during dinner preparation and service, between the hours 3:52 PM - 6:14 PM. 11/13/24 - During an interview, E1 (NHA) confirmed that E70 (kitchen cook), who was the cook in the kitchen during dinner preparation, did not possess a valid Food Protection Manager certificate from an Accredited Food Safety Program.

Inspectors wrote2. Surveyor observations on 10/28/24 at 2:45 PM and 10/29/24 at 3:23 PM revealed the following: C hallway room [ROOM NUMBER]: - The bathroom lacked a hand soap dispenser, and the hand sanitizing gel dispenser was empty; - Holes on the bathroom wall were present where the previous soap dispenser had been located; - The ventilation grate on the bathroom door had visible areas of rust; - The bathroom floor in bathroom appeared dirty; - The walls in the bedroom were in disrepair, with visible peeling paint. 10/30/24 8:15 AM - Observations of the E wing linen closet revealed a minimal supply of linens: - 2 fitted sheets; - 5 flat sheets; - No washcloths or towels. 10/30/24 8:20 AM - During an interview E23 (CNA) confirmed the lack of linens in the E wing linen closet. [...]

Inspectors wroteBased on record review and interview, it was determined that for one (R125) out of six residents reviewed for transfer/discharge, the facility failed to implement a policy allowing R125 to return to the facility after his 10/31/23 hospitalization. The facility refused to allow R125 to return to the facility due to lack of a payor source and he remained unnecessarily hospitalized for an additional 91 days. The facility also failed to allow R125 to return to the facility while appealing this discharge.

Inspectors wrote4. Cross refer F700, example 6 Review of R76's clinical record revealed: 2/22/23 - R76 was admitted to the facility. 10/28/24 11:30 AM - During an observation a left sided quarter bed rail was in place in place on R76's bed. 11/7/24 - A review of R76's care plan revealed the lack of a care plan focus for the bed rail on R76's bed. 11/12/24 1:32 PM - During an interview, E3 (LPN) confirmed the lack of a care plan focus area for R76's bed rail.

Inspectors wrote4. Review of R18's clinical record revealed: 11/18/09 - R18 was admitted to the facility. 9/27/24 - R18's quarterly MDS documented that R18 had multiple current diagnoses including dysphagia (difficulty swallowing), right sided paralysis following a stroke and that R18 had a feeding tube. 11/7/24 - A review of R18's care plan lacked the infection control focus for EBP. 5. Review of R55's clinical record revealed: 12/13/17 - R55 was admitted to the facility. R55 had multiple current diagnoses including dysphagia (difficulty swallowing) and left sided paralysis following a stroke. and that R55 had a feeding tube in place. 9/30/24 - R55's quarterly MDS documented that R55 had multiple current diagnoses, including dysphagia (difficulty swallowing) and left sided paralysis following a stroke. R55 had a feeding tube in place. [...]

Inspectors wrote2. Review of R15's clinical record revealed: 9/20/23 - R15 was admitted to the facility. 9/22/24 to 9/26/24 - R15 admitted to the hospital. 9/27/24 - R15 re-admitted to the facility after hospital stay. 9/27/24 - E55 (LPN) completed the following facility required admission Assessments: A. Resident Basics/Vitals/Medical History, B. Sensory/Facility Orientation/Elopement Risk, C. Pain, D/E. Musculoskeletal/Fall/Lift/Side Rail or Grab/ Skin Integrity/Braden Scale, F. Oral/Nutrition, G. Respiratory/Smoking, H. Bowel & Bladder, and I. IV/Other. An LPN, not an RN as required by the State of Delaware regulation for the Board of Nursing Scope of Practice, completed the initial assessments. 3. Review of R102's clinical record revealed: 8/20/23 - R102 was admitted to the facility. 9/20/24 to 9/22/24 - R102 admitted to the hospital. 9/22/24 - R102 re-admitted to the facility after hospital stay. [...]

Inspectors wrote5. Review of R60's clinical record revealed: 3/31/17 - R60 was admitted to the facility. 8/1/24 - R60's MDS documented that R60 had a BIMS of 10, indicating moderate cognitive impairment, and had diagnoses of high blood pressure and arthritis. 10/28/24 9:05 AM - An observation revealed a quarter length (22 inches) side rail on the right side of R60's bed. Review of R60's clinical record lacked evidence of the following: -the date that the bed rail was installed; -the attempt to use appropriate alternatives prior to installing the bed rail; -an assessment of R60 for the risk of entrapment from the bed rail prior to installation; -the presence of the informed consent for the use of a bed rail -review that the bed dimensions are appropriate for the resident's size and weight. [...]

Inspectors wrote2. 10/31/24 - An observation on the B unit from 9:07 AM through 9:55 AM revealed the following residents' meal trays which did not include coffee or tea beverages contrary to what was indicated in their breakfast meal tickets: R14 - no coffee or hot tea; R106 - no coffee or hot tea; R105 - no coffee or hot tea; R52 - no unsweetened coffee or hot tea; R103 - no coffee or hot tea; R78 - no unsweetened coffee or hot tea; R99 - no coffee or hot tea; R11 - no coffee or hot tea; and R69 - no coffee or hot tea. 10/31/24 9:13 AM - During an interview, E65 (CNA) confirmed that R14, R106 and R105 did not have coffee nor tea on their meal trays. 10/31/24 9:23 AM - In an interview, E64 (CNA) confirmed that R52, R103, R78, R99, R11 and R69 did not have coffee nor tea on their meal trays. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure food/items were stored and/or prepared under sanitary conditions.

Inspectors wroteBased on record review and interview, it was determined that for eleven (R16, R18, R33, R38, R43, R55, R94, R113, R310, R456 and R457) out of forty-two residents reviewed for resident records, the facility failed to maintain complete, accurate and readily accessible resident medical records.

Inspectors wroteBased on record review and interview, it was determined that for seven (R14, R25, R92, R102, R120, R314 and R456) out of thirteen residents reviewed for infection control, the facility failed to maintain an infection control program that included enhanced barrier precautions for residents who met the criteria. In addition for R25, high-contact suprapubic care was provided on 10/31/24 without the staff wearing the appropriate PPE. Direct care was provided to R14 on 11/7/24 without the staff wearing appropriate PPE. An environmental tour confirmed several observations of infection control issues.

Inspectors wroteBased on record review and interview, it was determined that for three (R147, R307 and F606) out of twenty-one residents reviewed for antibiotic stewardship, the facility failed to ensure that antibiotics were prescribed in accordance with recognized standards. For R606 the facility also failed to ensure the antibiotic was placed on the line list.

Inspectors wroteBased on record review and interview, it was determined that for four (R15, R33, R102 and R138) out of eight residents reviewed for vaccines, the facility failed to have evidence in each resident's medical record the administration of the influenza and/or pneumococcal vaccines.

Inspectors wroteBased on observation, interview and record review, it has been determined that for five (R26, R29, R62, R81 and R82) randomly observed during the survey, the facility failed to ensure each resident were treated with respect and dignity.

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that for three (R20, R78 and R80) out of four sampled residents reviewed for activities, the facility failed to allow cognitively intact residents the choice to go outside on their own or alone.

Inspectors wroteBased on record review and interview, it was determined that for one (R159) out of four residents reviewed for beneficiary notification, the facility failed to provide R159's responsible party with the required notification of the expiration of her Medicare of benefit.

Inspectors wroteBased on interview and record review, it was determined that for one (R14) out of seven residents reviewed for hospitalization, the facility failed to report the injury of unknown origin, which resulted in an emergent transfer to the hospital for treatment, to the State Agency.

Inspectors wroteBased on observation, record review, interview and review of other documentation as indicated, it was determined that for one (R14) out of seven residents reviewed for hospitalizations, the facility failed to have evidence that R14's injuries of unknown origin were thoroughly investigated.

Inspectors wroteBased on record review and interview, it was determined that for one (R102) out of six residents reviewed for transfer/discharges, the facility failed to notify the Ombudsman of R102's 4/27/24 transfer to the hospital.

Inspectors wroteBased on record review and interview, it was determined that for one (R158) out of the residents reviewed in the investigative sample, the facility failed to ensure the Minimum Data Set (MDS) was accurate.

Inspectors wroteBased on record review and interview, it was determined that for two (R141 and R125) out of two sampled residents reviewed for PASARR, the facility failed to notify the appropriate state-designated authority when the residents' new diagnosis of mental disorder were identified.

Inspectors wroteBased on record review and interview, it was determined that for one (R157) out of 42 residents reviewed in the investigative sample, it was determined that the facility failed to ensure that the baseline care plan was provided to the resident/resident representative.

Inspectors wroteBased on observation, interview, record review and review of other facility documentation, it was determined that for two (R20 and R80) out of four sampled residents reviewed for activities, the facility failed to provide outdoor activities during appropriate weather based on their comprehensive assessments and care plans.

Inspectors wroteBased on observation, interview and record review, it was determined that for one (R92) out of three residents reviewed for bladder continence, the facility failed to ensure that R92 received services and assistance to maintain bladder continence to the extent possible.

Inspectors wroteBased on interview and review of the facility clinical record and dialysis record, it was determined that for one (R102) out of two residents reviewed for dialysis, the facility failed to have ongoing collaboration with R102's dialysis center with respect to her dialysis labs (monthly and weekly) from June 2024 through November 2024.

Inspectors wroteBased on observation, interview and record review, it was determined that for one (R141) out of 13 residents reviewed for food, the facility failed to ensure that R141's food was prepared and appropriate to meet R141's needs and according to his care plan.

Inspectors wrote2. 11/1/24 11:00 AM - R78 reported that the facility breakfast meal is always determined by the kitchen, and that there are no alternative meal choices for breakfast. Additionally, there are no breakfast items on the always available menu. 11/12/24 8:30 AM - During an interview, E28 (Food Service Director) confirmed that the facility does not have an alternative breakfast menu and that there are no breakfast items on the always available menu food list.

Inspectors wrote2. Cross refer F561 and F802, example 2 11/1/24 11:00 AM - During an interview, R78 stated that the facility does not always provide evening snacks. R78 stated that because the timing of each meal is unpredictable, and that bedtime snacks are sometimes not provided, she was aware that many of the residents in the facility stored food in their rooms. R78 stated that they cannot depend on the facility to provide their food or bedtime snacks timely.

Inspectors wroteBased on record review and interview, it was determined that for two (R25 and R33) out of eight residents reviewed for vaccines, the facility failed to record R25 and R33's COVID vaccines in their medical records.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to have the survey results from the past three years available in a readily accessible area for residents, family members and legal representatives.

Inspectors wroteBased on observation, interview, record review and other facility documentation it was determined that for one (R313) out of one resident reviewed for wandering and elopement the facility failed to provide adequate supervision that contributed to the elopement of R313 and put the resident at immediate jeopardy and risk of a serious adverse outcome. R313 was able to elope from the facility on 9/17/22 and wander to a neighborhood behind the facility, fell in a driveway and was taken to the hospital by ambulance. An immediate jeopardy (IJ) was identified starting on 9/17/22. Due to the facility's corrective measures following the incident, this is being cited as immediate jeopardy, past non-compliance with an abatement date of 9/19/22.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to recognize, evaluate and address R198's hydration status to ensure R198 maintained proper hydration and health. This failure caused harm to R198 as evidenced by R198's insufficient fluid intake and diminished hydration status which resulted in R198's hospitalization with a critically high sodium level and a diagnosis of dehydration.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents' expired and discontinued medications were removed from medication carts for six of six medication carts. Resident (R) 12, R18, R23, R47, R116, R138, R299, R448, R87, R22, R32, R62, R109, R121, R34, R56, R65, R118, R128, R122, R124, R125, R301, R302, R13, R103, R129, R140, R457, and R458 had expired or discontinued medications on the medication carts. This created the potential for medications to be diverted or for residents to receive medications with no current physician order. Additionally, it was determined that the facility failed to permit only authorized personnel to have access to the keys to locked compartments containing medications. [...]

Inspectors wroteBased on observations and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure a clean and homelike environment for 13 resident rooms out of 89 sampled resident rooms. This failure had the potential for decreasing the independence and safety of the residents.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to properly maintain clean filters on oxygen concentrators for six of eight residents sampled for respiratory care (Resident (R) 403, R402, R93, R103, R38, and R43). The facility also failed to properly administer nebulizer treatments for two residents (R43, and R121) two residents sampled. The facility failed to maintain supplemental oxygen for one of one dependent residents (R30).

Inspectors wroteBased on record review and interview it was determined that for one (resident (R) 251) out of one resident reviewed for insulin use, the facility failed to prevent significant medication errors when R251 received insulin greater than one hour after the ordered time repeatedly from December 2022 through May 2023.

Inspectors wroteBased on observations, interviews, record reviews and facility policy review, the facility failed to have an effective infection control program to mitigate the spread of infections. The facility failed to ensure proper cleaning and disinfecting of multi-use glucometers; failed to ensure proper use of Personal Protective Equipment for residents on enhanced precautions; failed to ensure PPE was properly used for standard precautions; and failed to ensure proper hand hygiene was performed in between glove changes.

Inspectors wrote2. Review of R249's clinical record revealed: 8/28/21 - A significant change MDS documented R249 as cognitively intact and having a very important preference to choose between bath, shower, bed bath, and sponge bath. R249's care plan for ADL deficit last updated 3/8/22 included the intervention to assist in showering and/or bathing needs with extensive to total assist of one person and needs extensive assist with personal hygiene with one person. 2/18/22 - A quarterly MDS assessment documented R249 as cognitively intact and in need of extensive assistance of one staff person for hygiene and needing physical help of one staff person for bathing. January 2022 - March 2022 - Review of documentation of showers completed for R249 revealed the resident was to be offered a shower on each Sunday and Wednesday during the day shift. R249 received showers the following dates: [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure six of 32 sampled residents (Resident (R) 38, R50, R398, R119, R123 and R118) or their surrogate decision maker were provided written information informing them of their right to formulate an advanced directive.

Inspectors wroteBased on record review, it was determined that for one (R307) out of five residents reviewed for nutrition, the facility failed to consult the physician of the significant change in R307's weight. During the first nine months of R307's admission, R307 lost a documented 67.9 pounds.

Inspectors wroteBased on record review and interview, it was determined that for two (R123, R200) out of twenty-nine residents reviewed for assessments, the facility failed to accurately reflect the residents' status in their admission MDS assessments.

Inspectors wroteBased on record review and interview, it was determined that for one (R50) out of two residents reviewed for PASARR (Preadmission Screening and Assessment Resident Review), the facility failed to refer R50 for a PASARR Level II after R50 was diagnosed with delusional disorder.

Inspectors wrote2. Review of R308's clinical record revealed: 6/8/22 - R308 was admitted to the facility. 6/8/22 8:01 pm - An admission progress note documented R308 had an active left AV fistula (an abnormal connection between an artery and a vein for dialysis) and a non-active AV fistula in the right upper arm. 10/30/23 12:35 PM - The DON confirmed that the care plan for R308 had not been developed to identify that R308 had an AV fistula in both arms. The facility failed to develop a care plan that identified R308 had AV fistulas in both arms. Based on observations, interviews, record reviews, and facility policy review, the facility failed to develop a comprehensive care plan for three of 38 sampled residents (Resident (R) 140, R308 and R309). This failure had the potential to leave the resident with unmet care needs. [...]

Inspectors wroteBased on record review and interviews, it was determined that for three (R73, R95 and R123) out of six residents reviewed for care plans, the facility failed to ensure that the residents or the resident's representative was invited to participate in their care plan meetings.

Inspectors wroteBased on record review and interview, it was determined that for one (R307) out of seven residents reviewed for hospitalization, the facility failed ensure follow-up appointments and diagnostic tests were scheduled timely after a hospital stay.

Inspectors wroteBased on record review and interview, it was determined that for two (R200, R248) out of two reviewed for bladder continence, the facility failed to ensure that the residents received appropriate treatment and services to maintain highest practicable urinary function.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure appropriate care of a gastrostomy (g-tube) during medication administration for three residents (Resident (R) 30, R43 and R95) of three residents during medication administration with gastric tubes. Specifically, Licensed Practical Nurse (LPN) 14 and LPN17 failed to check for proper g-tube placement, did not flush the g-tube before and after medication administration, and administered medication via push method rather than by gravity administration for R43. LPN23 failed to check for proper g-tube placement, administered water flush via push method, and administered medications via push method rather than by gravity method for R95. This failure increases the risk for nausea, vomiting, or aspiration.

Inspectors wroteBased on record review and interviews, it was determined that for one (R50) out of three residents reviewed for Physician services, the facility failed to ensure that R50's total program of care, including R50's advanced directives, was reviewed by the providers at the time of his admission.

Inspectors wroteBased on record review and interview, it was determined that for one (CNA6) out of five certified nursing assistants (CNA) reviewed for Registry verification, the facility failed to ensure that CNA6, who successfully completed an out of state CNA competency evaluation program, went on to register with the State of Delaware.

Inspectors wrote2. Review of R307's clinical record revealed: 2/2/22 - R307 underwent bilateral above the knee (AKA) amputations. 2/17/22 - R307 was admitted to the facility with diagnoses including, but were not limited to, stroke, diabetes and bilateral above the knee amputations. 2/18/22 - NP's progress note documented, . Physical exam: . Skin: Bilateral AKA's with staples, clean, dry and intact. Left AKA with light purple ecchymosis . 2/23/22 - E17's (Wound Specialist NP) progress note documented, . Pt seen this am on wound round and noted with: L (left) abdomen- trauma. Review of Daily Skilled Notes revealed: 2/25/22 - E18 (Unit manager) documented, . No surgical wound noted. No wound noted . 3/2/22 10:45 PM - LPN15 documented, . No surgical wound noted. No wound noted . 3/13/22 9:00 PM - LPN2 documented, . No surgical wound noted. No wound noted . 3/14/22 7:52 PM - LPN2 documented, . [...]

Inspectors wroteBased on observations and interview, it was determined that the facility failed to ensure all mechanical, electrical and patient care equipment is maintained in safe operating condition.

Inspectors wroteBased on record review and interview it was determined that for three Residents (R) 248, R250 and R314) out of three new admissions reviewed the facility failed to ensure that a baseline care plan summary was provided to the resident/responsible party (RP).