Wilton Manors Healthcare & Rehabilitation Center

Inspectors wroteBased on review of policy and procedure, record review and interview, the facility failed to ensure that residents received appropriate care and treatment to prevent an evolving change in condition and status for 1 of 1 sampled resident reviewed, Resident #113.

Inspectors wrote3. Review of the American Dietetic Association titled National Dysphagia Level 2: Mechanically Altered Nutrition Therapy showed the following: for vegetables, it is recommended to be soft, well cooked, should be less than 1/2 inch, and easily mashed with a fork. 3a. Record review revealed Resident #230 was admitted to the facility on [DATE] with diagnoses of Unspecific Protein-Calorie Malnutrition, Unspecific Dementia, and Muscle Weakness. On 06/16/25 at 12:44 PM, an observation was conducted, during which Resident #230 was noted in her room eating her lunch meal, being assisted by staff. The meal ticket listed the following: a mechanically altered ground diet with pureed fruits and vegetables, collard greens, macaroni and cheese, a dinner roll, ground ham, and banana pudding. [...]

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and sanitary conditions and to prevent foodborne illnesses during two of the two visits to the main kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were treated in a dignified manner while providing dining assistance during 1 of 3 dining observations conducted, affecting Resident #285.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure call light devices were within reach of 4 of 93 rooms, room numbers 23, 25, 29 and 104.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to initiate a care plan for Enhanced Barrier Precautions (EBP) for 1 of 29 sampled residents, Resident #328.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide assistance during dining for 1 of 1 sampled resident, reviewed for activities of daily living (ADLs), Resident #330.

Inspectors wroteBased on interviews, observations, and record review, the facility facility failed to ensure that services and treatment were provided to increase or maintain range of motion (ROM) and to prevent potential decrease in ROM, as ordered by physicians, for 2 of 2 sampled residents, reviewed for ROM, Residents #51 and #62.

Inspectors wroteBased on review of policy and procedure, observation, interview and record review, the facility failed to follow proper technique and infection control practices during catheter care observation for 1 of 1 sampled resident observed, Resident #113.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to complete a nutrition assessment in a timely manner for 1 of 3 sampled residents reviewed for nutrition, Resident #231.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have dialysis communication sheets readily available for the continuation of care for 1 of 2 sampled residents reviewed for dialysis, Resident #231.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to accurately assess a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) and establish triggers for PTSD for 1 of 1 sampled resident reviewed for PTSD, Resident #58.

Inspectors wrote4. Record review revealed Resident #231 was admitted to the facility on [DATE] with diagnoses to include End Stage Renal Disease, Diabetes, and Anemia. The 5-day MDS dated [DATE], showed that Resident #231 had a BIMS score of 9, indicating moderate cognitive impairment. The Initial Nutrition assessment, dated 06/10/25, showed that Resident #231 was at increased risk for altered nutritional status, and it was recommended to provide double protein with meals. In an observation conducted on 06/16/25 at 12:37 PM, Resident #231 was eating his lunch meal. The closer observation showed the meal ticket with the following: Controlled Carbohydrates Renal diet, double protein, baked pork chops, buttered green, buttered pasta, and cornbread. The lunch plate was observed with the following: [...]

Inspectors wrote4. Record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses to include Major Depressive Disorder and Unspecific opened wound. An order was noted for Enhanced Barrier Precautions-wound every shift, which was dated 05/20/25. An observation was conducted on 06/16/25 at 11:30 PM of Staff B, Occupation Therapist, who was noted coming out of Resident #38's room with a gown. She was observed walking over to a Personal Protective Equipment (PPE) box located on the wall in the hallway. She grabbed a surgical mask with her bare hands and continued to put on gloves without practicing hand hygiene first. Staff B took a Hoyer lift and walked into Resident #38's room to assist him from the bed to the wheelchair with another staff member who was already in the room. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat a resident with a left-hand contracture for 1 of 1 sampled resident reviewed for a range of motion (ROM), Resident #108.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide nutritional interventions in a timely manner to prevent further weight loss for 1 of 5 sampled residents reviewed for nutrition, Resident #101.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the correct food consistency for 3 of 3 sampled residents who were on a mechanical soft / chopped, who were observed during dining, Resident #34, Resident #87, and Resident #230. This has the potential to affect 30 residents on a mechanical soft/chopped diet. The census at the time of the survey was 138 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain a proper sanitizing solution in the central kitchen for 2 of 3 red buckets observed during the initial tour of the kitchen; and failed to offer or encourage hand hygiene prior to dining for 5 of 5 sampled residents observed during dining, Residents #10, #24, #381, #99, and #69.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide restorative rehabilitation services in a manner that promotes the highest practicable level of functioning for 1 of 5 sampled residents receiving restorative services during dining (Resident #10).

Inspectors wroteBased on observation and interview, it was determined the facility failed to treat 3 of 3 sampled residents, Resident's #95, #105,and #281, and potentially 132 facility residents, with respect and dignity in a manner that promotes enhancement of quality of life that includes providing drinking cups and glasses with meals.

Inspectors wroteBased on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to ensure it secured and locked over-the-counter (OTC) expired and prescription medications for 5 of 5 residents observed during an observational room tour, Resident #80, Resident #77, Resident #68, Resident #230 and Resident #40; failed to ensure it kept its facility emergency crash cart locked and secured; failed to ensure it disposed of an expired stock medication in the South wing Treatment cart; and failed to ensure it secured loose unidentified medication pills for 1 of 6 observed medication carts during the Medication Storage Observation for the North wing medication cart.

Inspectors wroteBased on interview, observations and records review, the facility failed to ensure that 1 of 2 sampled residents (Resident #102) received an adaptive call light to notify staff of her needs.

Inspectors wroteBased on interviews and records review, the facility failed to ensure protection of 1 of 1 sampled resident's, Resident # 328, personal property from loss or theft.

Inspectors wroteBased on review of policy and procedure, observation, interview and record review, it was determined that the facility failed to provide care and services in accordance with activities of daily living: nail grooming for 1 of 1 sampled resident's observed, Resident #60.

Inspectors wroteBased on interviews, observations and records review, the facility failed to comprehensively assess 1 of 1 sampled resident (Resident #39) to determine her needs for hearing aids; and failed to promptly identify Resident #39's need for reading glasses and ensure an ophthalmological evaluation was performed timely.

Inspectors wroteBased on record review, observations, interviews and the facility's policy review, the facility failed to ensure that residents received care and services for the provision of parenteral fluids consistent with professional standards of practice for 1 of 1 sampled resident reviewed for Intravenous Antibiotic (IV) therapy, Resident #178, as evidenced by failure to change the IV Access Line dressing per the facility's policy and the facility's Intravenous (IV) Access Line Maintenance Protocol; failed to administer / infuse IV antibiotic in the pharmacy prescribed timeframe; and failed to have physician orders for IV flushes to maintain the IV-line which were being administered by the nurses.

Inspectors wroteBased on review of policy and procedure, interview, and record review, it was determined that the facility failed to ensure that it maintained eighteen (18) months' worth of daily nurse staffing data, as recorded.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to provide lab services to meet the needs on 1 of 1 sampled resident, Resident #99, reviewed for labs.

Inspectors wroteBased on observation, interview and record review, it was determined the approved Pureed Diet menu did not meet nutritional needs and was not followed for 14 facility residents with physician ordered Pureed Diets, which included 3 of 3 sampled Residents #28, #88, and #167.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to follow physician ordered therapeutic diet for Fluid Restriction for 1 of 5 sampled residents, Resident #281, reviewed for nutrition.