John Knox Village Of Pompano Beach

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to follow the approved menu for substitutions for residents with orders for mechanically altered diets for 3 of 27 sampled residents with orders for mechanical soft diets (Resident #18, #178 and #182). The findings included:Record review revealed the approved menu for the lunch meal on 07/28/25 documented that residents with orders for Mechanical Soft textures were to be served three-bean salad in place of coleslaw. The approved menu for the breakfast meal on 07/29/25 documented that residents with orders for Mechanical Soft textures were to be served bite sized sausage patties in place of bacon strips 1. Resident #178 was admitted to the facility on [DATE]. According to the resident's admission Evaluation, with a reference date of 07/23/25, Resident #178's cognition was documented as 'Alert and lethargic', with unclear speech and was 'sometimes' able to understand. The assessment documented that the resident was dependent upon staff for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide the correct diet consistency for the Mechanical Soft diet for 3 of 3 sampled residents reviewed for Nutrition (Resident #32, Resident #177 and Resident #162).The findings included:1. Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of Parkinsons Disease without Dyskinesia and Chronic Obstructive Pulmonary Disease. The admission Medicare - 5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's Brief Interview of Mental Status (BIMS) score was 13, which indicates intact cognition.A review of physician orders dated 07/14/25 revealed the following: Regular diet, Mechanical Soft Ground/Moist texture and thin consistency.In an observation conducted on 07/28/2025 1:00 PM, this surveyor observed that Resident #32's meal tray consisted of a chopped crispy fish sandwich. The bread was cut into two triangular pieces without borders.2. Record review revealed that Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to follow the professional standards of practice regarding the care and management of a resident receiving a nebulizing therapy for 1 of 3 sampled residents (Resident #96); failed to conduct an electrical safety inspection for a nebulizing treatment machine for 1 of 3 sample residents (Resident #92); failed to follow their own policy for verifying a practitioner's orders for nebulizing therapy for 1 of 3 sampled residents (Resident #156); failed to comply with the standards of transmission-based precautions during a nebulizing therapy; and failed to care and manage the nebulizing therapy supplies after a treatment for 1 of 3 sampled residents (Resident # 96). The findings include: A review of a facility policy titled, Nebulizer Therapy, with a revision date of 01/25, revealed the following: Nebulizer treatments, once ordered, is to be administered by nursing staff as directed using proper technique and standard precautions; verify…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, interviews and record reviews, the facility failed to follow the professional standards of practice regarding following physician orders of not taking blood pressure (BP) on the left arm for 1 of 1 sampled dialysis resident (Resident #9). The facility also failed to follow the physician order for fluid restriction for 1 of 1 sampled dialysis resident (Resident #9). The findings include: Review of a facility policy titled, Dialysis Care and Services, undated, revealed that elder guests who require dialysis receive such care and services consistent with professional standards of practice, the comprehensive person-centered care plan, and the elder's guest's goals and preferences. Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses that included Metabolic Encephalopathy, End Stage Renal Disease (ESRD), and Dependence on Renal Dialysis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/08/25, documented under Section C of the Brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to follow the standards or transmission-based precautions for 1 of 3 sampled residents for nebulizing therapy (Resident # 96), for 1 sampled resident for gastrostomy tube feeding (Resident #63), and for 1 of 2 sampled residents reviewed for urinary care (Resident #138). The facility additionally failed to initiate Enhanced Barrier Precautions (EBP) for 1 of 3 sampled residents (Resident #9). The facility also failed to follow its own appearance policy regarding wearing false and polished fingernails for 3 of 3 sampled residents (Resident #96, Resident #138, and Resident #9). The findings include:The findings included: A review of facility's policy titled, Nebulizer Therapy, undated, revealed the following:It is to be administered by nursing staff as directed using proper techniques and standard precautions. [NAME] gloves and other personal protective equipment (PPE) as needed to comply with standard or transmission-based precautions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide housekeeping and mainteance services necessary to maintain a sanitary, orderly, and comfortable interior for the following: [NAME] House (8 of 12 resident rooms), [NAME] House (8 of 12 resident rooms), Poinciana House (8 of 12 resident rooms), Egret House (7 of 12 resident rooms), Pine House (3 of 12 resident rooms), and Magnolia House (2 of 12 resident rooms). The findings included: 1) During the resident screenings conducted on 04/01/24 at 9 AM, and the Environment Tour conducted of the Seventh Floor ([NAME] House and Poinciana House) on 04/01/24 at 11:30 AM with the facility's Assistant Director of Maintenance and Registered Nurse Training Educator, the following were noted: [NAME] Unit (Rooms #7101-7112): room [ROOM NUMBER]: Room chair exterior worn and soiled, room walls (4) noted damaged and in disrepair with numerous areas of large black scuff marks, and bathroom toilet paper holder broken. room [ROOM NUMBER]: The portable over-commode…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for potentially 47 residents residing within the [NAME] House (11 Residents), Dolphin House (13 Residents), Egret House (12 Residents, and Oak House (11 Residents). The findings included: 1) During the kitchen sanitation tour of the [NAME] House conducted on 04/01/24 at 9 :30 AM and accompanied with the facility's Registered Nurse Educator, the following were noted: (a) The interior of the kitchen ovens (2) were noted to be heavily worn, soiled, and covered with carbon build-up. (b) The exteriors of the kitchen cabinets were noted to be heavily worn, had areas of peeling paint, and numerous areas of dried food matter. (c) The ceiling mounted air-conditioning vent located over the serving preparation area of the kitchen was noted with a build up of dust and black mold type matter. (d) The ceiling area (4 feet) around the air-conditioning vent had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to implement measures for infection control practices during laundry services for the Woodland Houses and Seaside Cove. In addition, the facility failed to maintain a sanitary laundry area for their central laundry. The findings included: Review of the facility's policy titled, Laundry Services- Handling of Soiled and Contaminated Laundry, undated, included the following: To implement practices on proper handling of laundry/personal clothing that prevent gross microbial contamination of the air and persons handling the linen. Guiding Principles: Sorting of each resident's linen/laundry and identification during laundry process will be done to prevent cross contamination and inaccurate distribution. Availability of (PPE) Protective Personal Equipment (e.g. gowns if soiling of clothing is likely). Sanitation of machine basket between each use. Clean lint catcher in dryer after each use. Proper infection control practices. Guide or Designee will provide education to Shahbaz on the proper handling of soiled and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, it was determined that the facility staff were responsible for causing the resident call system to be ineffective on resident rooms located on resident's the Egret Unit, [NAME] Unit, Poinciana Unit, and Ibis Unit that effected Resident's #82, #38, #125, #28, #54, #157, #69, #24, #126, and #378. The findings included: 1) During the observation tour conducted of the of [NAME] Unit (Room's #7101-7112) and the Poinciana Unit (Room's # 7201-7212) on 04/01/24 at 12:30 PM, accompanied with the facility's Registered Nurse Educator, [NAME]/Poinciana Guide, and Assistant Director of Maintenance, it was noted that the bathroom emergency call pull cords were wrapped around the wall handrails or were placed on top of the sink vanity. Both resulted in the call bells being not able to be pulled or reached by staff and/or residents during in need of assistance or emergency. The specifics included the following: (a) Resident #82 (room [ROOM NUMBER]) - review of the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to assess 1 of 1 sampled resident (Resident #63) for the use of bilateral full bed rails; failed to determine a medical symptom for the need of the bilateral use of full bed rails; and failed to obtain a consent from the resident's representative to use the full bed rails. The findings included: Review of the facility's policy titled Proper Use of Bed Rails revised on 01/2023 documents .physical restraint is defined as any manual method, physical or mechanical device, equipment .that meets all of the following criteria: is attached or adjacent to the resident's body; cannot be removed easily by the resident .resident assessment must also assess the resident's risk from using bed rails potential risks with the use of bed rails include: accident hazards (e.g. entrapment and other injuries sustained from attempts to climb over, around, between or through the rails .barrier to residents from safely getting out of bed .the facility will assess…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policy and procedure, observation, record review and interview, it was determined that the facility failed to obtain a physician's order for the monitoring and the continued care and services of a left arm skin tear wound and of a right lower leg blood-filled blister for 1 of 1 sampled residents observed, (Resident #150). The findings included: Review of the facility policy and procedure titled, Skin Tear, provided by the Director of Nursing (DON) with a reviewe date of 07/14/23, documented in the Policy Statement: .7. Put an order into Point-Click-Care (PCC) to monitor skin tear to the affected area for signs of bleeding and infection Record review revealed Resident #150 was re-admitted to the facility on [DATE], with diagnoses which included Type II Diabetes Mellitus, Acute Kidney Failure, Parkinson's Disease, Vascular Dementia, Anemia, Multiple Sclerosis, Bradycardia, Hypertension, Atherosclerotic Heart Disease and Cardiac Pacemaker. He had a Brief Interview Mental Status (BIM) score of 15…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for the Woodland Home (Swan, Orchid, Dove, Magnolia, Ibis, Seagrape, Egret, Pine, [NAME], [NAME], and Poinciana) and Seaside Cove (Sailfish and Pompano). The findings included: 1) During the initial screening of residents and observation of their rooms on 1/17/23 and the Environmental Tour of the Woodland Building, conducted on 1/18/23 at 1 PM accompanied by the Administrator, the following were noted: Swan Home (Rooms #2101-2112): room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks, bathroom door exterior noted to have numerous large black scrapes and scuff, and the television was not working. room [ROOM NUMBER] - Room walls noted to be in disrepair and numerous large black scrapes and scuff marks, bathroom door exterior was noted to have numerous large black scrapes and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of policy and procedure, the facility failed to ensure that it secured and locked ten (10) over-the-counter (OTC) and two (2) un-ordered prescription medications for 6 of 6 sampled residents observed, (Resident #54, Resident #19, Resident #136, Resident #26, Resident #70 and Resident #148); and, the facility failed to promptly discard two (2) expired OTC medications for 1 of 1 sampled resident (Resident #26). The findings included: Review of the facility policy and procedure titled, Storage of Medications, provided by the Director of Nursing (DON), revised [DATE], documented, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner Policy Interpretation and Implementation 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician ordered Fluid Restriction/Renal Diet for 1 of 9 sampled residents selected for nutritional review (Resident #35). The findings included: 1) Review of the facility's policy for Restricting Fluids noted the following: * When a resident has been placed on restricted fluids, remove the water pitcher and cup from the room. Remove all fluid containers from the room 2) Review of the facility's Renal Diet noted the following: * Fruits- Not Recommended - High Potassium foods including Oranges * Vegetables Not Recommenced - High Potassium foods including Potatoes During the review of the clinical record of Resident #35, it was noted that the resident's admission date to the facility was on 06/06/22. The resident's diagnoses included, End Stage Renal Disease, Dependence on Renal Dialysis, Acute Kidney Failure, Chronic Kidney Disease Stage IV, and Hyponatremeia. Resident #35's Current Physician Orders included: * 11/9/22 - Fluid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.