Deerfield Beach Health and Rehabilitation Center

Inspectors wroteBased on observations and interviews, the facility failed to provide comfortable water temperatures for bathing and showering, for the total of 88 residents, residing on the C and D Wing of the facility.

Inspectors wrote2) A record review showed that Resident #287 was admitted to the on 02/27/25 with diagnoses of Type 2 Diabetes, Altered Mental Status, and Anorexia. The admission Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview of Mental Status (BIMS) score of 13, indicating the resident is cognitively intact. In an interview conducted on 03/03/25 at 10:55 AM, Resident #287 stated that she verbally asked a staff member 20 minutes ago for assistance to get out of bed to her wheelchair and is still waiting. This Surveyor then asked her if she could use the call light on her bed to call for assistance. Resident #287 pressed the round call light on her bed, but no light was noted outside her room. Continued observation in the nurse's station did not show any light or noise on the call light box for Resident #287's room. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to address a grievance in a timely manner, regarding personal belongings for 1 of 1 sampled resident (Resident #90) reviewed for grievances.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assist during dining and provide nutritional supplements in a timely manner for 1 of 6 sampled residents reviewed for nutrition (Resident #288); and the facility failed to accurately assess the nutritional status of 1 out of 2 sampled residents reviewed for tube feeding (Resident #158).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide proper care and documentation of the tracheostomy and failed to assess the resident for self-care of tracheostomy for 1 of 1 sampled resident reviewed for tracheostomy care (Resident #87). The facility also failed to properly date the oxygen tubing for 1 of 1 sampled resident reviewed for oxygen therapy (Resident #4); and failed to properly store the nebulizer mask for 1 of 1 sampled resident reviewed for respiratory therapy (Resident #21).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to identify a resident's Post-Traumatic Stress Disorder (PTSD) trigger to deliver competent trauma informed care and failed to initiate a care plan identifying a specific PTSD trigger for a trauma informed care for 1 of 1 sampled resident (Resident #103), reviewed for [NAME]-Informed Care.

Inspectors wroteBased on review of policy and procedure, record review and interview, it was determined that the facility failed to ensure that it maintained sufficient nursing staff, on a 24-hour basis to provide nursing and related services to residents, in order to maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.

Inspectors wroteBased on review of policy and procedure, observation and interview, the facility failed to secure medication carts for 3 of 8 sampled medication carts observed (Medication cart back and front C-wing area and back area of B-wing); and, failed to ensure keys to the medication carts are secured at all times, for 1 of 8 sampled Medication carts observed, (D-wing).

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure an effective QAPI plan in place to prevent repeated deficiencies for 3 out of 10 previously cited deficiencies (F584 Safe/Clean/Comfortable/Homelike Environment, F692 Nutrition/Hydration Status Maintenance , F695 Respiratory/Tracheostomy Care and Suctioning).

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide an essential equipment with safe operating condition, and failed to provide a safe, sanitary and comfortable environment for 2 of 2 sampled residents, Resident #4 and Resident #5, and random room observations, as evidenced by a leaking air conditioner with water pooling under Resident #4's bed and water with an offensive odor coming from the residents' bathroom / shower areas and additional offensive odors in the A-shower room and room [ROOM NUMBER].

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide nutritional interventions in a timely manner, failed to assist during dining, failed to ensure the accuracy of the scales, and failed to identify a significant weight loss for 2 of 4 sampled residents reviewed for nutrition (Resident #111 and Resident #143).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to monitor the nutritional status in a timely manner and failed to conduct weekly weights as per the facility's policy to identify a significant weight loss of 21% of body weight for 1 of 2 sampled residents reviewed for tube feeding (Resident #169).

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure clean bed linens are provided to residents for 2 of 34 sampled residents sampled (Resident #10 and #137) and failed to ensure all areas and equipment are in good repair.

Inspectors wroteBased on review of policy and procedure, observation, record review and interview, the facility failed to provide care and services in accordance with activities of daily living including: nail grooming for 2 of 2 sampled residents observed, (Resident #327 and Resident #79).

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide proper treatment and care for good foot health in a timely manner for 1 out of 5 sampled residents reviewed for ADL (Activities of Daily Living) care (Resident #40).

Inspectors wroteBased on interviews, observations, and record review, the facility failed to ensure that services or treatment to increase range of motion (ROM) and to prevent further decrease in ROM was provided as ordered for 1 of 2 sampled residents (Resident # 116 ) reviewed for ROM.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) ensure that it properly and correctly positioned the Foley catheter tubing for 1 of 2 sampled residents observed and reviewed for Foley Catheters (Resident #160); and 2) failed to ensure that it properly anchored the Foley catheter for 2 of 2 sampled residents observed for Foley Catheters (Resident #160 and Resident #53).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide proper tracheostomy care and maintain a sterile field for 1 of 1 sampled resident reviewed for tracheostomy care (Resident #74). The facility also failed to obtain a physician's order for oxygen for 1 of 3 sampled residents (Resident #79) and failed to properly document the use of oxygen for 1 out of 3 sampled residents (Resident #96) reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review; it was determined that the medication error rate was 7.59 percent, 2 medication errors were identified while observing a total of 26 opportunities, affecting Resident #91 and Resident #479.

Inspectors wroteBased on observation and interview the facility failed to equip the corridor between the therapy rooms with firmly secured handrails on each side.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior on 4 (A-Wing, B-Wing, C-Wing, and D-Wing) of 4 residential wings.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to dispose of garbage and refuse properly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address long fingernails for 1 of 3 sampled residents reviewed for Activities of Daily Living (ADL), Resident #370; and failed to ensure assistance during dining for 1 of 1 ampled residents, Resident #92.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that enteral nutrition had been followed by the practitioner's order and ensure that the tube feeding order was meeting the estimated needs for 2 of 3 sampled residents (Residents #371 and Resident #55) reviewed for tube feeding.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 of 1 sampled residents (Resident #166) reviewed, who requires dialysis, received services consistent with professional standards of practice that include the administration of physician ordered dialysis medications.

Inspectors wroteBased on policy and procedure review, observation, interview and record review, it was determined that the facility failed to 1) ensure that it secured and locked un-ordered, and expired over-the-counter (OTC) medications for Resident # 97; 2) ensure that it secured and locked dry eye medication for Resident # 104; 3) ensure that it secured and locked a tube of Bacitracin Zinc Antibiotic ointment for Resident # 135, observed during an observational room tour; 4) promptly dispose of a prescription expired liquid medication in one (1) of four (4) medication rooms, medication room A-wing; 5) ensure that it promptly dispose of two (2) (OTC) stock Hemorrhoidal cream medications in one (1) of two (2) treatment carts, treatment cart A-wing during a Medication Storage Observation; [...]