Inspection Reports for Coral Springs Rehabilitation and Healthcare Center
DE, 19808
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 7, 2025, found the facility to be in substantial compliance with no deficiencies identified. Earlier inspections showed multiple deficiencies related mainly to resident care, staffing levels, care planning, and environmental cleanliness, as well as issues with food safety, infection control, and documentation. Prior reports also noted problems with medication management, resident rights, and supervision during activities. Complaint investigations were unsubstantiated or did not identify deficiencies. The facility appears to have made improvements over time, with the latest follow-up survey confirming compliance after previous citations.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
22.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
155% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
153 residents
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 4
Dec 8, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident rights, abuse reporting, investigation, accident prevention, and overall facility safety.
Findings
The facility was found deficient in respecting a resident's right to refuse medication, timely reporting of abuse and injuries of unknown origin, thorough investigation of abuse allegations, and ensuring resident safety during mechanical lift transfers. Several residents were affected by these deficiencies, with minimal harm or potential for actual harm noted.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to respect a resident's right to refuse a medication for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report allegations of abuse or injuries of unknown origin to the state survey agency for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to thoroughly investigate an allegation of staff-to-resident physical and verbal abuse for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were free from accident hazards related to inappropriate use of a mechanical lift for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for choices: 7
Residents affected by abuse reporting deficiency: 3
Residents reviewed for abuse or injuries: 7
Residents reviewed for accidents: 10
Residents affected by mechanical lift accident: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #13 | Registered Nurse | Named in medication administration and refusal incident with Resident #181 |
| LPN #1 | Licensed Practical Nurse | Named in staff-to-resident abuse allegation involving Resident #185 |
| CNA #2 | Certified Nursing Assistant | Witness and reporter of abuse allegation involving Resident #185 |
| RN Supervisor #3 | Registered Nurse Supervisor | Received abuse report from CNA #2 and reported to DON |
| LPN Supervisor #4 | Licensed Practical Nurse Supervisor | Interviewed regarding bowel protocol and abuse investigation |
| LPN #14 | Licensed Practical Nurse | Reported injury of unknown origin and described bowel protocol |
| DON | Director of Nursing | Oversaw abuse investigations and described facility policies |
| Administrator | Facility Administrator | Provided statements on abuse reporting and investigation |
| LPN #7 | Licensed Practical Nurse | Interviewed regarding mechanical lift accident involving Resident #184 |
| CNA #8 | Certified Nursing Assistant | Involved in mechanical lift accident with Resident #184 |
Inspection Report
Follow-Up
Census: 153
Deficiencies: 0
Feb 7, 2025
Visit Reason
An unannounced Follow-Up Survey to the Annual and Complaint Survey ending November 15, 2024, was conducted at this facility from February 6, 2025, through February 7, 2025.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as of January 2, 2025. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 25
Inspection Report
Complaint Investigation
Deficiencies: 17
Nov 15, 2024
Visit Reason
The inspection was conducted based on complaints and investigations related to resident care, safety, and regulatory compliance at Springs Rehabilitation at Brandywine.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare beneficiary notifications, inadequate housekeeping and maintenance, failure to timely report suspected abuse, incomplete investigations of injuries, failure to notify ombudsman of transfers, improper admission and post-fall assessments by unlicensed personnel, inadequate pain management, failure to collaborate with dialysis providers, food service deficiencies including lack of qualified food safety personnel and delayed meal deliveries, failure to provide drinks consistent with resident preferences, improper food storage, incomplete medical records, and inadequate antibiotic stewardship.
Complaint Details
The visit was complaint-related, investigating multiple allegations including failure to provide Medicare notifications, inadequate care and treatment, failure to report abuse, improper discharge and transfer notifications, and other regulatory compliance issues.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 15
Level of Harm - Actual harm: 2
Deficiencies (17)
| Description | Severity |
|---|---|
| Failed to provide resident R159's responsible party with required Notice of Medicare Non-Coverage and option to appeal, resulting in out-of-pocket payment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a safe, clean, comfortable environment including adequate housekeeping, maintenance, and linen supply. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse and thoroughly investigate injuries of unknown origin for resident R14. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify Ombudsman of resident R102's hospital transfer. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement policy allowing resident R125 to return after hospitalization, resulting in unnecessary prolonged hospitalization. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate Minimum Data Set (MDS) assessment for resident R158, omitting documentation of bipap use. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement individualized care plans for seizure disorder and bed rail usage for residents R41, R14, R67, and R76. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate pain management for resident R157 prior to wound care, resulting in pain and harm. | Level of Harm - Actual harm |
| Failed to ensure ongoing collaboration with dialysis center for resident R102 regarding dialysis labs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure qualified food service personnel with valid Food Protection Manager certificates and timely meal delivery; breakfast trays not served within 45 minutes of scheduled time. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide drinks consistent with resident needs and preferences for 9 residents on the B unit. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide evening snacks consistently for residents R23 and R78. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food and items were stored and prepared under sanitary conditions including uncovered food, food debris, and lack of paper towels at handwashing sink. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain complete, accurate, and readily accessible resident medical records for eleven residents including missing urine culture reports and inaccurate documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure anticoagulation medications had adequate medical diagnoses as indications for use for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure initial admission and post-fall assessments were completed by Registered Nurses as required by state regulations for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement an antibiotic stewardship program ensuring antibiotics were prescribed in accordance with recognized standards and properly documented for residents R147, R307, and R606. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days of bowel protocol not initiated: 13
Number of residents with missing or incomplete medical records: 11
Number of residents with inadequate pain management: 1
Number of residents with missing individualized care plans for bed rails or seizure disorder: 4
Number of residents with unqualified personnel completing assessments: 5
Number of residents not provided drinks consistent with preferences: 9
Number of residents not provided evening snacks: 2
Number of residents reviewed for antibiotic stewardship: 21
Number of residents with inadequate antibiotic stewardship: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA | Named in multiple findings including Medicare notification failure, housekeeping, abuse reporting, transfer notification, food service deficiencies, and antibiotic stewardship |
| E2 | DON | Named in multiple findings including Medicare notification failure, housekeeping, abuse reporting, transfer notification, food service deficiencies, and antibiotic stewardship |
| E4 | LPN/QA/IC | Named in findings related to abuse reporting, antibiotic stewardship, and assessments |
| E3 | MD | Named in findings related to pain management, antibiotic orders, and medical record reviews |
| E52 | NP | Named in findings related to pain management, antibiotic orders, and medical record reviews |
| E58 | RDO | Named in findings related to Medicare notification failure, housekeeping, transfer policy, pain management, and food service |
| E47 | RCC | Named in findings related to transfer notification, pain management, food service, and medical record reviews |
| E27 | ADON | Named in findings related to transfer notification, pain management, assessments, and medical record reviews |
| E24 | LPN | Named in findings related to post-fall assessments |
| E6 | LPN | Named in wound care progress note |
| E21 | RN | Named in bowel protocol and urine culture documentation |
| E22 | CNA | Named in bowel movement size interview |
| E23 | CNA | Named in bowel movement size interview |
| E55 | LPN | Named in admission assessments and antibiotic stewardship |
| E60 | LPN | Named in admission assessments |
| E61 | LPN | Named in admission assessments |
| E62 | LPN/UM | Named in admission assessments |
| E33 | Regional Dietary Consultant | Named in food service and meal delivery findings |
| E8 | Dietary Supervisor | Named in food service and meal delivery findings |
| E70 | Kitchen Cook | Named in food service findings for lack of food safety certification |
| E34 | Regional Dietary Consultant | Named in drink provision findings |
| E42 | CNA | Named in evening snack findings |
| E43 | CNA | Named in evening snack findings |
| E41 | CNA | Named in evening snack findings |
| E40 | RN | Named in food storage findings |
| E4 | LPN/IP | Named in antibiotic stewardship and urine culture documentation |
| E52 | NP | Named in antibiotic stewardship and pain management |
| E24 | LPN | Named in post-fall assessment findings |
| E15 | RN | Named in enteral feed water flush documentation |
| E60 | LPN | Named in admission assessments |
| E4 | LPN/IP | Named in urine culture documentation |
| E1 | NHA | Named in multiple findings including Medicare notification failure, housekeeping, abuse reporting, transfer notification, food service deficiencies, and antibiotic stewardship |
Inspection Report
Routine
Deficiencies: 21
Nov 15, 2024
Visit Reason
The inspection was a routine regulatory survey of Springs Rehabilitation at Brandywine to assess compliance with healthcare facility regulations, including resident care, infection control, safety, and food service.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, self-determination, access to survey results, environmental cleanliness, care planning, medication and assessment practices, activity provision, food service quality, infection control, antibiotic stewardship, and vaccination documentation. Several residents were affected by these deficiencies, with some deficiencies causing minimal harm and others actual harm.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 19
Level of Harm - Actual harm: 2
Level of Harm - Potential for minimal harm: 1
Deficiencies (21)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated with respect and dignity, including improper catheter bag placement visible from hallway. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to promote and facilitate resident self-determination through support of resident choice, including restrictions on outdoor access and late meal deliveries. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to allow residents to easily view nursing home survey results and communicate with advocate agencies. | Level of Harm - Potential for minimal harm |
| Failure to maintain a safe, clean, comfortable and homelike environment, including inadequate housekeeping, maintenance, and linen supply. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely notification to the resident and ombudsman before transfer or discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to coordinate assessments with pre-admission screening and resident review program (PASARR) and notify appropriate authorities of new mental disorder diagnoses. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement complete care plans that meet residents' needs, including seizure disorder and bed rail usage. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop, review, and revise comprehensive care plans by a team of health professionals, including infection control precautions and activity plans. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure services meet professional standards of quality, including having LPNs complete assessments outside their scope and failure to have RN complete post-fall assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide activities to meet residents' needs, including outdoor activities during appropriate weather. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care according to orders, resident preferences and goals, including inadequate pain management resulting in hospitalization. | Level of Harm - Actual harm |
| Failure to try different approaches before using bed rails and failure to assess, obtain informed consent, and maintain bed rails properly. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure each resident receives food prepared in a form designed to meet individual needs, including failure to provide prescribed regular texture food. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure each resident receives drinks consistent with resident needs and preferences, including failure to provide coffee or tea with breakfast. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure meals and snacks are served at times in accordance with resident needs, preferences, and requests, including failure to provide evening snacks. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to procure food from approved sources and store, prepare, distribute and serve food in accordance with professional standards, including unsanitary kitchen conditions and improper food storage. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to safeguard resident-identifiable information and maintain complete, accurate, and readily accessible medical records. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement an infection prevention and control program including enhanced barrier precautions for residents with indwelling devices and wounds, and failure to use appropriate PPE during care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement a program that monitors antibiotic use, including lack of urine culture evidence and incomplete antibiotic line list documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement policies and procedures for flu and pneumonia vaccinations, including failure to document administration or refusal in resident records. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible residents and staff after education, and properly document vaccination status. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days without enhanced barrier precautions: 46
Days without enhanced barrier precautions: 103
Shifts without bowel protocol: 26
Shifts without bowel protocol: 16
Shifts with pain medication: 6
Missed water flush volume: 3500
Missed water flush volume: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E25 | CNA | Named in catheter bag visibility and dignity issue finding. |
| E26 | LPN | Named in catheter bag visibility and dressing change without gown. |
| E2 | DON | Confirmed multiple findings including catheter bag, care plans, infection control, and food service issues. |
| E1 | NHA | Reviewed findings and confirmed multiple deficiencies. |
| E4 | LPN/QA/IP | Confirmed care plan and infection control deficiencies. |
| E16 | Activities Director | Interviewed regarding outdoor activities and resident participation. |
| E47 | Regional Clinical Consultant | Reviewed and confirmed findings related to activities, care plans, and infection control. |
| E55 | LPN | Completed admission assessments outside RN scope. |
| E24 | LPN | Completed post-fall assessment outside RN scope. |
| E56 | LPN | Interviewed regarding food preferences and meal tray content. |
| E8 | Dietary Supervisor | Confirmed meal delivery delays and food service deficiencies. |
| E33 | Regional Dietary Consultant | Confirmed food service staffing and meal delivery issues. |
| E22 | CNA | Interviewed regarding resident continence care. |
| E23 | CNA | Interviewed regarding resident continence care. |
| E57 | RNAC | Interviewed regarding voiding diary and toileting plan. |
| E6 | LPN, wound care | Documented wound infection progress note. |
| E52 | NP | Ordered medications and documented wound care and antibiotic stewardship. |
| E69 | RN, Night shift Supervisor | Interviewed regarding enhanced barrier precautions and PPE availability. |
| E67 | CNA | Observed providing care without PPE. |
| E68 | CNA | Interviewed regarding enhanced barrier precautions. |
| E17 | Regional Maintenance Director | Conducted environmental tour and confirmed findings. |
| E18 | Environmental Services Director | Conducted environmental tour and confirmed findings. |
| E40 | RN | Confirmed food storage deficiencies. |
| E4 | LPN/IP | Confirmed infection control and antibiotic stewardship deficiencies. |
| E31 | RD | Interviewed regarding food service responsibilities. |
| E70 | Kitchen cook | Did not possess valid Food Protection Manager certificate. |
| E62 | LPN/UM | Completed admission assessments outside RN scope. |
| E60 | LPN | Completed admission assessments outside RN scope. |
| E61 | LPN | Completed admission assessments outside RN scope. |
Inspection Report
Annual Inspection
Census: 153
Deficiencies: 17
Nov 15, 2024
Visit Reason
An unannounced annual and complaint survey was conducted at Springs Rehabilitation at Brandywine LLC from October 28, 2024, through November 15, 2024, to assess compliance with federal and state regulations for skilled and intermediate care nursing facilities.
Findings
The facility was found to have multiple deficiencies including failure to provide residents with updated resident rights, inadequate nursing staffing levels on some days, failure to treat residents with respect and dignity, incomplete admission and discharge notifications, inadequate care planning, and issues with environmental cleanliness and safety. Root causes often involved lack of staff understanding or failure to follow policies. Plans of correction were submitted with targeted completion dates.
Deficiencies (17)
| Description |
|---|
| Failure to provide updated resident rights to all residents both orally and in writing. |
| Failure to provide minimum nursing staffing levels of 3.28 hours of direct care per resident on four out of 39 days reviewed. |
| Failure to ensure residents were treated with respect and dignity, including improper handling of Foley catheter bags and lack of supervision during meals. |
| Failure to provide timely and proper notification of transfer or discharge to residents and responsible parties. |
| Failure to develop and implement comprehensive, person-centered care plans including baseline care plans and plans for residents with seizures and other conditions. |
| Failure to maintain a safe, clean, comfortable, and homelike environment, including dirty floors, broken fixtures, and inadequate linen supply. |
| Failure to properly assess and manage pain for residents with cognitive impairment. |
| Failure to thoroughly investigate and report alleged abuse and neglect incidents in a timely manner. |
| Failure to ensure residents receiving dialysis had proper care plans and laboratory results reviewed. |
| Failure to properly assess and monitor residents for risk of entrapment and to install and maintain bed rails safely. |
| Failure to ensure sufficient qualified staff in food service and to provide food that meets residents' preferences and dietary needs. |
| Failure to ensure residents' bowel and bladder continence care and protocols were properly implemented and monitored. |
| Failure to provide adequate care and pain management for residents with wounds and pressure injuries. |
| Failure to develop and implement care plans for residents with seizure disorders and other complex conditions. |
| Failure to ensure proper admission assessments and care planning for residents with mental health diagnoses. |
| Failure to maintain accurate and complete documentation of care and assessments. |
| Failure to ensure proper supervision and care during resident activities and outdoor access. |
Report Facts
Facility census: 153
Investigative sample: 91
Days reviewed for staffing compliance: 39
Days with insufficient staffing: 4
Residents reviewed for respect and dignity: 5
Residents reviewed for admission/discharge notification: 4
Residents reviewed for care plan accuracy: 6
Residents reviewed for pain management: 1
Residents reviewed for falls care plan: 5
Residents reviewed for bowel and bladder continence: 3
Residents reviewed for wound care: 1
Residents reviewed for seizure care plan: 1
Residents reviewed for admission assessments: 1
Residents reviewed for bed rail care plan: 7
Residents reviewed for food preferences: 13
Residents reviewed for bowel protocol: 1
Residents reviewed for dialysis care: 1
Residents reviewed for pain management: 1
Residents reviewed for admission assessments: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna P. Amos | Administrator | Named as provider's signature on multiple pages related to plan of correction and findings |
| E14 | Nursing Assistant | Interviewed regarding resident rights document awareness |
| E1 | Nursing Home Administrator | Interviewed and involved in review of findings and plan of correction |
| E2 | Director of Nursing | Interviewed and involved in review of findings and plan of correction |
| E47 | Regional Clinical Coordinator | Interviewed and involved in review of findings and plan of correction |
| E58 | Registered Dietitian | Interviewed and involved in review of findings and plan of correction |
| E53 | Certified Nursing Assistant | Observed during survey for resident care |
| E25 | Certified Nursing Assistant | Interviewed regarding resident care |
| E26 | Licensed Practical Nurse | Interviewed regarding resident care |
| E16 | Activities Director | Interviewed regarding resident activities and care plans |
| E55 | Regional Clinical Coordinator | Interviewed regarding resident care |
| E27 | Assistant Director of Nursing | Interviewed regarding resident care |
| E4 | Licensed Practical Nurse/Quality Assurance/Infection Preventionist | Interviewed regarding resident care |
| E54 | Registered Nurse | Interviewed regarding resident care |
| E62 | Licensed Practical Nurse/Unit Manager | Interviewed regarding admission assessments |
| E66 | Rehab Director | Interviewed regarding bed rails and rehabilitation |
| E18 | Environmental Services Director | Interviewed regarding environmental cleanliness |
| E23 | Certified Nursing Assistant | Interviewed regarding linen supply |
| E31 | Registered Dietitian | Interviewed regarding food service |
| E37 | Activities Staff | Interviewed regarding resident activities |
| E56 | Licensed Practical Nurse | Interviewed regarding food service |
| E8 | Dietary Supervisor | Interviewed regarding food service |
| E70 | Kitchen Cook | Interviewed regarding food service |
| E33 | Regional Dietary Consultant | Interviewed regarding food service |
| E21 | Registered Nurse/Unit Manager | Interviewed regarding bed rails and admission assessments |
| E24 | Licensed Practical Nurse | Interviewed regarding falls assessments |
| E54 | Registered Nurse | Interviewed regarding wound care |
| E52 | Nurse Practitioner | Interviewed regarding wound care |
| E2 | Director of Nursing | Interviewed regarding multiple findings |
| E57 | Registered Nurse Assessment Coordinator | Interviewed regarding assessments and care plans |
| E58 | Registered Dietitian | Interviewed regarding care plans |
| E41 | Nurse | Interviewed regarding pain management |
| E66 | Rehab Director | Interviewed regarding bed rails and rehabilitation |
Inspection Report
Annual Inspection
Deficiencies: 8
Nov 15, 2024
Visit Reason
The inspection was conducted as an annual survey of Springs Rehabilitation at Brandywine to assess compliance with federal regulations and standards for nursing facilities.
Findings
The facility was found deficient in multiple areas including food and drink provision, meal/snack frequency, food safety and sanitation, resident records confidentiality and accuracy, infection prevention and control, antibiotic stewardship, and COVID-19 immunization documentation. Deficiencies were discussed with facility leadership and plans of correction were outlined.
Severity Breakdown
SS=E: 6
SS=D: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to provide each resident with drinks consistent with their needs and preferences. | SS=E |
| Facility failed to ensure residents received evening snacks as required. | SS=D |
| Facility failed to ensure food items were stored and prepared under sanitary conditions. | SS=E |
| Facility failed to maintain complete, accurate, and readily accessible resident medical records. | SS=E |
| Facility failed to establish and maintain an infection prevention and control program. | SS=E |
| Facility failed to ensure an antibiotic stewardship program was implemented. | SS=E |
| Facility failed to ensure residents received influenza and pneumococcal immunizations or documentation thereof. | SS=E |
| Facility failed to ensure residents received COVID-19 immunizations or documentation thereof. | SS=D |
Report Facts
Residents reviewed for food and drink deficiencies: 13
Residents reviewed for medical records deficiencies: 42
Residents reviewed for antibiotic stewardship: 21
Residents reviewed for influenza and pneumococcal immunizations: 8
Residents reviewed for COVID-19 immunizations: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E34 | Regional Dietary Consultant | Stated facility policy on coffee/tea provision and meal ticket accuracy. |
| E1 | NHA (Nursing Home Administrator) | Participated in findings review and discussions. |
| E2 | DON (Director of Nursing) | Participated in findings review and discussions. |
| E47 | Regional Clinical Consultant | Participated in findings review and discussions. |
| E8 | Dietary Supervisor | Confirmed breakdown in kitchen system regarding coffee/tea provision. |
| C1 | Consultant Pharmacist | Confirmed lack of medical diagnoses for anticoagulant therapy. |
| E4 | LPN/IP | Confirmed laboratory report upload issues and participated in interviews. |
| E15 | RN | Confirmed medication administration record deficiencies. |
| E26 | Surveyor | Observed infection control practices. |
| E69 | RN Night Shift Supervisor | Observed PPE use and infection prevention compliance. |
Inspection Report
Follow-Up
Census: 163
Deficiencies: 0
Jan 18, 2024
Visit Reason
An unannounced Follow-Up Survey to the Annual and Complaint Survey ending November 8, 2023, was conducted at the facility from January 15, 2024 through January 18, 2024.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as of January 18, 2024. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 28
Inspection Report
Annual Inspection
Deficiencies: 15
Nov 8, 2023
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with healthcare regulations and standards for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to honor resident rights to self-determination, inadequate care planning, failure to ensure timely medication administration, improper infection control practices, failure to maintain accurate medical records, and unsafe medication storage and disposal practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Level of Harm - Potential for minimal harm: 1
Level of Harm - Actual harm: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to honor resident self-determination and choice regarding bathing and mobility. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to notify physician of significant weight loss in a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain a clean and homelike environment including dirty privacy curtains and unclean resident rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide baseline care plan summary to new admissions or their responsible parties. | Level of Harm - Potential for minimal harm |
| Failure to develop and implement comprehensive and person-centered care plans for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure appropriate follow-up appointments and diagnostic tests after hospital discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate catheter care and maintain urinary continence. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain adequate hydration resulting in hospitalization for dehydration and hypernatremia. | Level of Harm - Actual harm |
| Failure to ensure appropriate care of gastrostomy tubes during medication administration including checking placement, flushing tubes, and using gravity method. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure timely administration of insulin resulting in repeated late doses. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure expired and discontinued medications were removed from medication carts and failure to restrict access to medication storage to authorized personnel only. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain accurate and complete medical records including documentation of wounds and oxygen orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe and appropriate respiratory care including cleaning oxygen concentrator filters, proper nebulizer treatment administration, and maintaining supplemental oxygen. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement an effective infection prevention and control program including proper cleaning of multi-use glucometers, proper use of personal protective equipment, and hand hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Insulin late administrations: 23
Insulin late administrations: 25
Insulin late administrations: 14
Insulin late administrations: 16
Insulin late administrations: 23
Insulin late administrations: 21
Fluid intake (ml): 2520
Fluid intake (ml): 1960
Fluid intake (ml): 2040
Fluid intake (ml): 2280
Fluid intake (ml): 1800
Fluid intake (ml): 1320
Fluid intake (ml): 1080
Fluid intake (ml): 2000
Fluid intake (ml): 1020
Serum sodium level (mmol/L): 165
Serum chloride level (mmol/L): 123
Serum creatinine level (mg/dL): 2.53
Oxycodone tablets: 28
Oxycodone tablets: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide 15 | CNA | Interviewed regarding resident shower preferences and care |
| Director of Nursing | DON | Confirmed findings related to shower care and medication administration |
| Certified Nursing Assistant 13 | CNA | Interviewed regarding resident mobility and bedbound status |
| Registered Nurse 4 | RN Nursing Unit Manager | Interviewed regarding resident mobility and bedbound status |
| Surgical Oncologist | Physician | Documented resident weight loss history |
| Housekeeping Supervisor | HSK | Interviewed regarding cleaning deficiencies |
| Operations Maintenance Director | OMD | Conducted rounds and acknowledged cleaning and maintenance issues |
| Maintenance Director | MD | Conducted rounds and acknowledged cleaning and maintenance issues |
| MDS Coordinator 2 | MDSC | Confirmed unsigned baseline care plans |
| Physical Therapist 2 | PT | Confirmed resident splint usage |
| Licensed Practical Nurse 8 | LPN | Confirmed splint usage and care plan deficiencies |
| Director of Nursing | DON | Confirmed care plan deficiencies for CHF monitoring |
| Nurse Practitioner | NP | Confirmed care plan deficiencies for CHF monitoring |
| Unit Clerk 1 | UC1 | Documented appointment scheduling attempts |
| Unit Clerk 2 | UC2 | Described appointment scheduling process |
| Family Member 5 | FM5 | Reported concerns about follow-up appointment delays |
| Nursing Home Administrator | NHA | Reviewed findings and corrective actions |
| Certified Nursing Assistant 15 | CNA | Reported resident refusal of oxygen and feeding tube care |
| Licensed Practical Nurse 14 | LPN | Observed administering medications via feeding tube improperly |
| Licensed Practical Nurse 17 | LPN | Observed administering medications via feeding tube improperly |
| Licensed Practical Nurse 23 | LPN | Observed administering medications via feeding tube improperly and oxygen tank monitoring |
| Registered Nurse 10 | RN | Involved in medication diversion incident |
| Licensed Practical Nurse 15 | LPN | Involved in medication diversion incident |
| Licensed Practical Nurse 26 | LPN | Reported medication diversion incident |
| Registered Nurse 3 | RN | Observed medication diversion incident |
| Licensed Practical Nurse 8 | LPN | Observed dirty oxygen concentrator filters and confirmed cleaning needed |
| Licensed Practical Nurse 18 | LPN | Observed improper glucometer cleaning and PPE use |
| Wound Nurse | WND | Observed improper glove use during dressing change |
| Infection Prevention/Staff Development | IP/SD | Confirmed infection control deficiencies and provided education |
| Registered Nurse 7 | RN | Observed improper PPE use during accucheck |
| Regional Nurse | REG | Confirmed feeding tube medication administration PPE requirements |
Inspection Report
Annual Inspection
Deficiencies: 12
Nov 8, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare facility regulations, including resident rights, care planning, medication administration, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to honor resident self-determination, incomplete care plans, inaccurate assessments, inadequate supervision leading to resident elopement, improper medication administration and storage, failure to maintain equipment, and lapses in infection prevention and control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to honor resident self-determination related to shower preferences and assistance with bed mobility. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents or their representatives were invited to participate in care plan meetings. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop comprehensive and person-centered care plans for residents including identification of medical devices and monitoring needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate supervision to prevent elopement, resulting in immediate jeopardy to resident health and safety. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to ensure appropriate care of gastrostomy tubes during medication administration, including checking placement, flushing tubes, and using gravity method. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain clean oxygen concentrator filters and properly administer nebulizer treatments and supplemental oxygen. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure nurse aide was properly certified to work in the state. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to prevent significant medication errors related to late administration of insulin. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure expired and discontinued medications were removed from medication carts and failed to restrict access to medication storage to authorized personnel. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store, prepare, distribute and serve food in accordance with professional standards, including improper food storage and unclean food disposal. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain all mechanical, electrical and patient care equipment in safe operating condition, including broken refrigerator door gaskets. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have an effective infection control program including proper cleaning and disinfecting of multi-use glucometers, proper use of PPE for residents on enhanced and standard precautions, and proper hand hygiene. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Late insulin administrations: 23
Late insulin administrations: 25
Late insulin administrations: 14
Late insulin administrations: 16
Late insulin administrations: 23
Late insulin administrations: 21
Expired/discontinued medications: 30
Oxycodone tablets received: 30
Oxycodone tablets destroyed: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide 15 | CNA | Interviewed regarding shower assistance and resident preferences |
| Director of Nursing | DON | Confirmed findings related to shower assistance and care planning |
| Certified Nursing Assistant 13 | CNA | Interviewed regarding resident bed mobility and supervision |
| Registered Nurse 10 | RN | Involved in medication destruction incident and unauthorized access to medications |
| Licensed Practical Nurse 14 | LPN | Observed administering medications via g-tube improperly and glucometer cleaning |
| Licensed Practical Nurse 17 | LPN | Observed administering medications via g-tube improperly and glucometer cleaning |
| Licensed Practical Nurse 23 | LPN | Observed administering medications via g-tube improperly and glucometer cleaning |
| Licensed Practical Nurse 18 | LPN | Observed improper glucometer cleaning and PPE use |
| Registered Nurse 5 | RN | Interviewed regarding resident insulin administration delays and enhanced barrier precautions |
| Registered Nurse 7 | RN | Observed glucometer use and PPE practices |
| Licensed Practical Nurse 19 | LPN | Observed improper PPE disposal |
| Nurse Practitioner | NP | Interviewed regarding insulin administration and care planning |
| Nurse Practitioner 2 | NP | Interviewed regarding care planning and splint usage |
| Housekeeping Supervisor | HSK | Interviewed regarding cleaning deficiencies |
| Operations Maintenance Director | OMD | Interviewed regarding environmental concerns and window security |
| Maintenance Assistant 2 | MA2 | Interviewed regarding window security and elopement incident |
| Nursing Home Administrator | NHA | Participated in exit conferences and interviews regarding multiple findings |
| Social Work Assistant 1 | SSA1 | Documented family contact attempts for care plan meetings |
| Social Work Assistant 2 | SSA2 | Documented family contact attempts for care plan meetings |
| Physical Therapist 2 | PT | Confirmed resident splint usage |
Inspection Report
Annual Inspection
Census: 147
Deficiencies: 9
Nov 8, 2023
Visit Reason
An unannounced annual and complaint survey was conducted from 10/24/23 through 11/08/23 to assess compliance with 42 CFR 483 subpart B for Coral Springs Rehabilitation at Brandywine.
Findings
The facility was found not to be in substantial compliance with federal regulations. Deficiencies were identified related to resident care, documentation, and facility policies, including issues with cognitive assessments, advance directives, care planning, medication administration, and safety measures.
Deficiencies (9)
| Description |
|---|
| Facility failed to provide appropriate documentation of RSO's cognitive assessment or capacity determination. |
| Resident care plans were not consistently updated or implemented, including care for cognitive impairment and bathing assistance. |
| Facility failed to ensure residents' rights to make advance directives were consistently honored and documented. |
| Inadequate supervision and assistance to prevent resident elopement and wandering. |
| Failure to accurately document and monitor residents' continence status and toileting programs. |
| Inadequate assessment and care planning for residents with feeding tubes and respiratory needs. |
| Medication administration errors including failure to follow physician orders and improper storage of medications. |
| Failure to maintain a safe and homelike environment, including housekeeping and maintenance issues. |
| Failure to ensure adequate staff training and competency verification. |
Report Facts
Survey Census: 147
Sample Size: 38
Supplemental Residents: 67
Inspection Report
Annual Inspection
Deficiencies: 5
Nov 8, 2023
Visit Reason
The inspection was conducted as an annual survey of Springs Rehabilitation at Brandywine to assess compliance with Medicare and Medicaid regulations, including medication management, infection control, food safety, resident records, and equipment safety.
Findings
The survey identified multiple deficiencies including improper medication management with medications on hand without current orders, lapses in medication destruction protocols, food safety violations such as improper storage and thawing techniques, incomplete and inaccurate resident medical records, and infection control program deficiencies. The facility was required to implement corrective actions including staff education and process improvements.
Severity Breakdown
Severity D: 2
Severity E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Medications were found on hand with no current orders and improper medication destruction procedures. | — |
| Food safety violations including improper storage of cantaloupes and thawing of ham, and unclean food disposal. | — |
| Resident medical records were incomplete and inaccurate, lacking documentation for oxygen orders and surgical wound care. | Severity D |
| Infection prevention and control program was ineffective, with failures in hand hygiene, PPE use, and cleaning protocols. | Severity E |
| Mechanical and electrical patient care equipment was not maintained in safe operating condition due to broken refrigerator gaskets. | Severity D |
Report Facts
Date survey completed: Nov 8, 2023
Deficiency F761: Medication management deficiencies noted on multiple residents
Deficiency F812: Food procurement, storage, preparation, and sanitation deficiencies
Deficiency F842: Resident records - identifiable information and medical record accuracy
Deficiency F880: Infection prevention and control program deficiencies
Deficiency F908: Essential equipment safe operating condition deficiencies
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse RN10 | Named in medication error and drug diversion findings | |
| Licensed Practical Nurse LPN15 | Named in medication error and drug diversion findings | |
| Director of Nursing DON | Director of Nursing | Interviewed regarding medication destruction and drug diversion |
| Licensed Practical Nurse LPN26 | Named in medication error and drug diversion findings | |
| Food Service Director FSD | Food Service Director | Confirmed food safety findings and corrective actions |
| Licensed Practical Nurse LPN18 | Observed cleaning and infection control practices | |
| Registered Nurse RN14 | Observed infection control practices | |
| Licensed Practical Nurse LPN19 | Observed infection control practices | |
| Registered Nurse RN7 | Observed infection control practices |
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 4
May 6, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, dietary services, special equipment needs, and infection prevention and control at Springs Rehabilitation at Brandywine.
Findings
The facility was found deficient in providing oral care to a dependent resident, ensuring a resident received their preferred diet consistency, providing special eating equipment to prevent spills, and maintaining an effective infection prevention and control program including proper hand hygiene and equipment disinfection.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide oral care to one resident (R46) who was totally dependent on staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure one resident (R107) received her preferred and requested diet consistency. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide special eating equipment and utensils for one resident (R84) to prevent spilling drinks. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to establish and maintain an infection prevention and control program; staff failed hand hygiene and cleaning/disinfecting blood glucose meters between residents; failed to change oxygen tubing and humidifier bottle weekly for resident R16. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for ADL's: 5
Residents affected: 1
Residents reviewed for diet consistency: 66
Residents affected: 1
Residents reviewed for ADL's: 5
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E9 | CNA | Stated CNAs are not responsible for oral care on patients with tracheostomies |
| E8 | UM | Stated CNAs are responsible for oral care |
| E2 | DON | Confirmed deficient practice regarding oral care and special eating equipment; involved in exit interviews |
| E11 | RNAC | Confirmed deficient practice regarding oral care and special eating equipment; involved in exit interviews |
| E1 | NHA | Participated in exit conferences reviewing findings |
| E14 | ST (Speech Therapist) | Provided information on diet consistency and special eating equipment recommendations |
| E13 | OT | Verified diet communication slip and recommended special eating equipment |
| E5 | FSD (Food Service Director) | Discussed diet consistency findings and meal ticket updates |
| E7 | LPN | Observed failing to clean/disinfect blood glucose meter and perform hand hygiene |
| E6 | RN | Observed failing to disinfect blood glucose meter properly between residents |
| E4 | RN | Confirmed oxygen tubing and humidifier bottle were not changed weekly |
| E3 | ADON | Confirmed infection control deficiencies and participated in exit interviews |
| E10 | CNA | Provided information on resident profile and special eating equipment usage |
| E12 | LPN | Observed giving resident a drink without appropriate special cup |
| E18 | Dietician | Stated meal ticket should have been updated for diet consistency |
Inspection Report
Complaint Investigation
Census: 169
Deficiencies: 0
Aug 28, 2019
Visit Reason
An unannounced complaint survey was conducted at Brandywine Nursing & Rehabilitation Center on August 28, 2019.
Findings
No deficiencies were identified during the complaint survey conducted on August 28, 2019.
Complaint Details
The complaint survey was unannounced and conducted on August 28, 2019. No deficiencies were cited at the time of the survey.
Report Facts
Survey sample size: 3
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