Deerfield Beach Health And Rehabilitation Center

F-F584 Safe/Clean/Comfortable/Homelike Environment cited 11/09/23 included in part the following: failed to ensure all areas and

equipment are in good repair. Missing and crumbling plaster and vents with black mold-like substance. Refer to current citation for

F-F692 Nutrition/Hydration Status Maintenance cited 11/09/23 included in part the following: facility failed to provide nutritional interventions in a timely manner, failed to assist during dining. Refer to current citation for

F-F695 Respiratory/Tracheostomy Care and Suctioning.

Review of the QAPI meeting agenda for 12/08/23 documented the committee reviewed the annual survey plan of correction.

Review of the QAPI meeting agenda for 01/12/24 documented the committee reviewed the survey citations and audits.

Review of the QAPI meeting agenda for 02/09/24 documented the committee reviewed the annual survey corrections and deficiencies.

Review of the QAPI meeting agenda for 03/08/24 documented the committee reviewed the annual survey corrections and deficiencies.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 105622 Department of Health & Human Services Printed: 09/05/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105622 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Deerfield Beach Health and Rehabilitation Center 401 East Sample Road Pompano Beach, FL 33064

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 During an interview conducted on 03/06/25 at 12:00 PM with the Administrator and the Director of Nursing

they stated they have a monthly QAPI meeting. They have had ongoing audits and education, as well as Level of Harm - Minimal harm or collecting data, tracking and trending since last survey for nutrition (including supplements assisting with potential for actual harm feeding), tracheostomy care (education and competencies), and environment (including resident rooms, air conditioning vents). The environment, nutrition concerns and tracheostomy care have been discussed Residents Affected - Few monthly in QAPI as they are an ongoing QAPIs.

In summary the facility has collected data and had meetings to discuss QAPI but lacked measurable goals indicating if the individual QAPIs have improved, stayed the same or worsened to know if the QAPI has been effective.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 105622