Inspection visit
Inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to maintain dignity while dining for two residents
(Resident #24 and Resident #250) of 31 residents dependent on staff for dining.
Findings included:
1. An observation on 11/7/22 at 12:45 PM revealed Staff I, a Certified Nursing Assistant (CNA), standing
over Resident #24 feeding her lunch. No chair was observed in the room. Staff I stated she usually would
sit. She confirmed the policy was to sit when feeding a resident.
An observation on 11/8/22 at 12:52 PM revealed Staff J, CNA standing at the bedside of Resident #24. A
chair was to the side of the bed and observed to be at a height below the height of the bed. Staff J was
observed standing over the resident with a prepackaged drink in her hand. Also observed was the staff
member's cell phone lying on the bedside table of the resident next to her plate of food. The bed was
observed to be at waist height of the CNA while she was standing. Staff stated Resident #24 did not like the
lunch, and then looked down at her phone and swiped the phone screen during the observation and
interview. An attempted interview at this time with Resident #24 was unsuccessful. She would not respond.
A medical record review revealed the resident's cell phone and charger were in the safe.
A review of the resident's face sheet showed Resident #24 had an original admission date of 12/1/20 and a
readmission date of 8/4/22. The diagnoses included encounter for palliative care, legal blindness, anxiety
disorder and major depressive disorder.
Resident #24's Minimum Data Set assessment, dated 9/1/22, revealed in Section C for Cognitive Patterns a
Brief Interview for Mental Status (BIMS) score of 7, indicating severe impairment. Section G for Functional
Status indicated for Activities of Daily Living (ADLs) Assistance for Eating a score of 4for self- performance
and a score of 2 for support, indicating total dependence on staff with a one-person physical assist.
Resident #24's active care plans included the following:
-Focus of ADL Total, effective 8/25/22, showed: I (Resident #24) require extensive to total assistance with
all aspects of mobility and self-care, related significant change. I have been refusing medications,
treatments, and care and I also choose not to participate in my care at times. I may become feisty towards
staff and my caregiver. I am no longer ambulating and have had weight loss as I
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 9
Event ID:
105715
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105715
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/09/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hampton Court Nursing and Rehabilitation Center
16100 NW 2nd Avenue
North Miami Beach, FL 33169
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 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
sometimes choose not to eat or eat 25% (percent). I have had weight loss. My diagnoses include . cataracts
and I am legally blind. I am now enrolled in palliative care through hospice services related to my end stage
diagnosis. I continue to require total assistance because I am able to assist with ADLs, but I choose not to.
The interventions included assist me with meals and fluid intake. Record % consumed. Notify RD
(Registered Dietitian), SLP (Speech Language Pathologist), and my doctor of new onset signs of
chewing/swallowing difficulty promptly.
- Focus of Nutritional Status: Risk for Decline in Nutritional Parameters, effective 8/18/22, showed at times I
(Resident #24) report I receive the same foods every day, however this is due to my poor eyesight.
Interventions included, provide assistance as needed with meals and minimize distractions during meals.
On 11/9/22 at 12:36 PM, Resident #24 was observed in her room drinking tea from a straw in a coffee cup
and with her lunch tray set up for her and untouched. There was no staff member in the room assisting her.
She stated, It is hard for me because I can't see the food.
Review of the facility's policy titled, Meal Service, revised 5/25/21, revealed the policy as, It is the practice of
this facility to treat each resident with respect and dignity and care for each resident in a manner and in an
environment that maintains or enhances his or her quality of life, recognizing each resident's individuality
and protecting the rights for each resident. The Policy Explanation and Compliance Guidelines revealed, 1.
All staff members involved in providing feeding assistance to residents promote and maintain resident
dignity during mealtimes .4. Focus on the resident while talking to him/her and addressing him/her
individually, 5. All staff will be seated, if possible, while feeding a resident.
On 11/9/22 at approximately 2:00 PM, the Nursing Home Administrator (NHA) was interviewed. The NHA
confirmed the expectation was for staff to sit when providing assistance with feeding for a resident.
2.On 11/07/22 at 12:33 PM, an observation was made of Resident #250 in her room during lunch meal.
Staff G, a Certified Nursing Assistant (CNA) from an agency was observed standing while assisting the
resident with lunch meal. Staff G stated the resident was eating well, typical of her consumption which was
about 50%. Staff G did not know if she should be sitting during the process of providing assistance when
feeding a resident.
Review of the face sheet for Resident # 250 showed the resident was admitted to the facility on [DATE] with
diagnoses of history of intracerebral hemorrhage, Alzheimer's, diabetes, chronic kidney disease,
dyslipidemia, sepsis, hypertension, hyperlipidemia, depression, anemia, neuralgia/neuritis, hypothyroidism,
insomnia, and obesity.
Review of an active Care Plan for Resident #250, dated, 11/03/22, under nutritional status showed the
resident is at risk for decline in nutritional parameters due to advanced age, on a mechanically altered and
therapeutic diet, on diuretics and edema.
An intervention in the care plan showed to provide assistance with meals as needed.
Review of a document titled, Care Plan Activity Report, dated 11/4/22, showed an ADL focus indicating
Resident #250 requires limited assistance with eating.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105715
If continuation sheet
Page 2 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105715
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/09/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hampton Court Nursing and Rehabilitation Center
16100 NW 2nd Avenue
North Miami Beach, FL 33169
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 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
An interview was conducted on 11/08/22 at 12:50 PM with Resident #250 and the Director of
Rehabilitation. Resident #250 stated she did not speak English. The Director of Rehabilitation interpreted
for her. The Resident stated she can feed herself but will ask for help if needed. The Director of
Rehabilitation stated the resident does not require meal assistance all the time, she needs cues and
prompts and if the resident needed assistance, staff should provide assistance. The Director of
Rehabilitation stated if staff are assisting the resident, they should sit at eye level.
On 11/09/22 at 10:32 AM, an interview was conducted with Staff H, an agency CNA. Staff H stated, I was
trained when assisting a resident with a meal, sit them upright in bed, at an angle, place a clothing
protector on the resident if they wish, and then sit down next to them and take my time feeding them. Staff
H stated she asks the residents what they wanted and assists them accordingly.
On 11/09/22 at 9:45 AM, an interview was conducted with the Nursing Home Administrator (NHA). The
NHA stated some CNAs are new and they have forgotten the expectations related to meal supervision and
assistance. The NHA stated they have started in-services on basic nursing care expectations. The NHA
stated they did not have specific training material related to standing during meal assist. She stated it is an
assumed best practice to sit at eye level when assisting the resident with meal.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105715
If continuation sheet
Page 3 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105715
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/09/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hampton Court Nursing and Rehabilitation Center
16100 NW 2nd Avenue
North Miami Beach, FL 33169
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 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews and record review the facility failed to ensure reasonable accommodations were
provided to maintain independence for assistance related to the use of the call light for one resident
(Resident #53) out of two residents reviewed for pain.
Residents Affected - Few
Findings included:
On 11/07/22 at 10:35 a.m. Resident #53 was heard moaning in pain from the hallway. A staff member
entered the room to assist the resident and closed the door.
On 11/07/22 at 11:39 a.m. Resident #53 was observed in bed and moved her left hand to show the area of
pain she had in her right shoulder and neck area. Resident #53's call light was then observed to be
dangling from the headboard behind the right side of the head of her bed and out of reach.
On 11/07/22 at 11:40 a.m. Staff K, a Licensed Practical Nurse (LPN) confirmed Resident #53 was able to
use the call light. She assisted Resident #53 and placed the call light within reach of the resident, and
confirmed they have repositioned Resident #53 and provided her with Tylenol.
On 11/08/22 at 12:59 PM, Resident #53 was observed in bed covered and her lunch was on the bedside
table positioned across her bed and untouched. She stated she was no longer in pain and she was given
Tylenol and was feeling good. Resident #53 did not know where her call light was when asked. The call light
was then observed wrapped around the headboard and dangling so the bulb was touching the ground and
out of reach. (Photographic Evidence Obtained). At this time, Staff J, a Certified Nursing Assistant (CNA)
entered the room to assist and stated the call light should be clipped on and proceeded to clip the call light
to Resident #53's blanket. Resident #53 stated, I was looking for that.
A review of the Resident Face Sheet showed Resident #53 was admitted to the facility on [DATE]. The
diagnoses included pain and muscle weakness and type 2 diabetes mellitus with diabetic neuropathy.
Resident 53's Minimum Data Set (MDS) assessment, dated 8/25/22, revealed in Section C - Cognitive
Patterns a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired. Section G Functional Status indicated for Activities of Daily Living (ADLs) Assistance the resident needed extensive
assistance with bed mobility, dressing, and personal hygiene.
A review of Resident 53's active care plans included the following:
-Focus of Pain, effective as of 3/1/22, showed I (Resident #53) am at risk for Alteration in comfort: Pain
related to impaired mobility, weakness, diabetes with neuropathy and edema. Interventions included to
place call bell within easy reach when in room.
-Focus of ADLs, effective as of 3/1/22, showed I require assistance with my self care and mobility as
follows: supervision, set-up with cues at mealtime and extensive assist to total assist for bed mobility,
transfer, dressing, toileting, grooming, and bathing I have generalized weakness . Interventions included to
place items close to me.
In an interview on 11/08/22 at 4:22 p.m. Staff E, LPN stated, Yes, she (Resident #53) uses the call light.
She confirmed the expectation was the call light should be clipped onto the sheet. She
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105715
If continuation sheet
Page 4 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105715
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/09/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hampton Court Nursing and Rehabilitation Center
16100 NW 2nd Avenue
North Miami Beach, FL 33169
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 0558
Level of Harm - Minimal harm
or potential for actual harm
confirmed they (staff) check to make sure the call lights are in place when doing rounds, and positioning or
assisting a resident.
On 11/09/22 around 2:00 PM, the Nursing Home Administrator (NHA) confirmed the expectation was for
staff to ensure the call light was placed for the resident, so that it could be easily reached.
Residents Affected - Few
Review of the policy titled, Call Lights: Accessibility and Timely Response, revised 10/18/22, showed the
policy as: The purpose of this policy is to assure the facility is adequately equipped with a call light at each
residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly
relay to a staff member or centralized location to ensure appropriate response. The Policy Explanation and
Compliance guidelines showed: 1. All staff will be educated on the proper use of the resident call system,
including how the system works and ensuring resident access to the call light .5. Staff will ensure the call
light is within reach of resident and secured, as needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105715
If continuation sheet
Page 5 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105715
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/09/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hampton Court Nursing and Rehabilitation Center
16100 NW 2nd Avenue
North Miami Beach, FL 33169
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 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure one resident ( Resident #18) out of
seven residents reviewed for receiving oxygen via nasal cannula was free from the use of an unnecessary
medication.
Residents Affected - Few
Findings included:
An observation of Resident #18 was conducted on 11/7/22 at 12:28 PM, Resident #18 was observed to
have a nasal cannula pulled down around her neck with the oxygen concentrator running. The resident was
eating at the time.
An additional observation on 11/8/22 at 4:10 PM showed Resident #18 was lying in bed with a nasal
cannula in place with oxygen running at 3 liters per minute.
A review of admission records indicated Resident #18 was admitted on [DATE] with diagnoses including
hypertension, and chronic obstructive pulmonary disease.
Review of Resident #18's care plan records revealed the resident has a care plan in place for respiratory
disorders. The care plan does not mention the use of oxygen therapy.
A review of Resident #18 vital signs records showed oxygen saturation and respirations have been
monitored each shift with no abnormal values.
A review of Resident #18's medical records did not show an order for oxygen therapy. Resident #18's
transfer forms from her admission to the facility did not indicate the use of oxygen, nor did section O
(Special treatments, procedures, and programs) of her Minimum Data Set, dated [DATE].
A review of Resident #18's progress notes revealed nursing notes on 10/13, 10/22, and 10/29/22 that
indicated the resident was on oxygen via nasal cannula.
On 11/9/22 at 9:30 a.m. Resident #18 was lying in bed with the oxygen concentrator running at 3 liters per
minute with her nasal cannula in place (Photographic evidence obtained)
The Nursing Home Administrator provided a list of all facility residents that receive oxygen via nasal
cannula; Resident #18 was not included on that list.
An interview was conducted with Staff D, a Respiratory Therapist (RT) on 11/9/22 at 9:20 a.m. he stated
Resident #18 is not one of the residents he tracks. He stated for residents receiving oxygen via nasal
cannula, the nurse will get an order from the provider. He stated occasionally Respiratory Therapy is asked
to evaluate the resident if needed. He confirmed the resident should have an order for oxygen use.
An interview was conducted with the Director of Clinical Services on 11/9/22 at 10:08 a.m. She stated that
for a resident receiving oxygen via a nasal cannula the nurse will talk to the provider for an order unless it is
an emergency.
An interview was conducted with Staff E, Licensed Practical Nurse (LPN) on 11/9/22 at 10:37 a.m.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105715
If continuation sheet
Page 6 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105715
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/09/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hampton Court Nursing and Rehabilitation Center
16100 NW 2nd Avenue
North Miami Beach, FL 33169
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 0757
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Staff E stated she was assigned to Resident #18. She confirmed the resident is on oxygen via nasal
cannula. Staff E was observed reviewing Resident #18's orders. She stated she looked at the current order
and history and there is no oxygen order.
An interview was conducted with Staff F, Assistant Director of Nursing (ADON,) on 11/9/22 at 10:43 a.m.
She was observed reviewing Resident #18's medical record. She reviewed the history and current orders
and stated no, don't see any order. She said she looked at the PRN and regular orders. The ADON
confirmed the resident needs an order to be on oxygen. Staff F was also observed reviewing the nursing
progress notes. She confirmed there were multiple notes indicating the resident was using oxygen. She
stated there isn't any reason to keep looking back, she has been on it a while. She said she doesn't know
when or why the resident would have been put on oxygen. Staff F said she was going to get RT to assess
the resident and see if she needs the oxygen.
On 11/9/22 at 1:00 p.m. Staff D, RT stated Resident #18 has an oxygen saturation of 100% on oxygen. He
removed the oxygen and waited 15 minutes and reassessed and continued to monitor. He stated without
the oxygen she was maintaining an oxygen saturation of 97% and the oxygen was not needed.
A facility policy titled Oxygen Administration, dated 5/26/22 was reviewed. The policy stated the following:
Oxygen is administered to residents who need it, consistent with profession standards of practice, the
comprehensive person-centered care plans and the residents' goals and preferences.
1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case,
oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is
under control.
4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's
assessment and orders, such as, but not limited to:
a. The type of oxygen delivery system.
b. When to administer, such as continuous or intermitted and/or when to discontinue.
A facility policy titled Unnecessary Drugs-Without Adequate Indication for Use, dated 10/20/22 was
reviewed. The policy stated the following:
3. Documentation will be provided in the resident's medical record to show adequate indications for the
medication's use and the diagnosed condition for which it was prescribed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105715
If continuation sheet
Page 7 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105715
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/09/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hampton Court Nursing and Rehabilitation Center
16100 NW 2nd Avenue
North Miami Beach, FL 33169
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 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure that the medication error rate was
below 5.00%. A total of twenty-five medications were observed, and six medications errors were observed
for two residents (Resident #66 and Resident #305) out of five residents observed for medication
administration. The medication errors constituted a medication error rate of 24 percent.
Residents Affected - Few
Findings included:
A medication administration observation was conducted with Staff A, Registered Nurse (RN) on 11/8/22 at
9:12 a.m. Staff A prepared medication for Resident #66. Staff A removed two Lidocaine 4% Pain Relief
patches from the medication cart. She stated the resident gets one on each of her knees. Staff A
proceeded to place a Lidocaine path on the front of Resident #65's left and right knee just below the knee
cap.
The order reconciliation revealed an order for Resident #66 for a Lidocaine Pain Relief Patch 4% to be
applied topically to the affect area of the right knee for up to 12 hours. There was no order located for a
Lidocaine Patch for the left knee.
A review of admission records indicated Resident #66 was admitted on [DATE] with diagnoses including
generalized arthritis, and pain.
An interview was conducted with Staff A, RN on 11/8/22 at 2:33 p.m. Staff A reviewed Resident #66 and
confirmed the order for a Lidocaine Pain Relief Patch 4% was only for the right knee. Staff A stated the
resident requested it for her left knee as well because it was hurting. Staff A reported she said, that is
where the most pain was. Staff A confirmed she did not call the provider. Staff A stated she will talk to the
charge nurse and get her to call the doctor for an order. Staff A stated there were no other orders for
medication for the the left knee.
An interview was conducted with Staff C, RN, Charge Nurse on 11/8/22 at 2:43 p.m. Staff C stated
Resident #66 has had issues with her right knee and that is why she get the Lidocaine patch. The resident
still has pain in her right knee and the patch is only for the right knee. Staff C confirmed Resident #66
should not be getting a Lidocaine Pain Relief Patch 4% on her left knee without an order. Staff C stated that
she thought the resident only had one on her right knee and she was not aware of her getting a patch on
the left knee. Staff C stated she would speak with the nurse and call the doctor for an order.
A review of progress notes revealed a note dated 11/8/22 at 3:35 p.m. indicating the provider was called
regarding Resident #66's left knee pain and an order was obtained.
A medication administration observation was conducted with Staff B, Licensed Practical Nurse (LPN) on
11/8/22 at 10:47 a.m. Staff B prepared the following medications to administer to Resident #305: Metformin
500 mg (milligram), Memantine 5 mg, Losartan 100 mg/Hydrochlorothiazide 25mg, Plavix 75 mg,
Amlodipine 10 mg, and Acetaminophen 325 mg two tablets. The medications were administered to the
resident at 10:50 a.m.
An order reconciliation revealed that Metformin 500 mg, Memantine 5 mg, Losartan 100
mg/Hydrochlorothiazide 25mg, Plavix 75 mg, and Amlodipine 10 mg were all scheduled to be administered
at 9:00 a.m.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105715
If continuation sheet
Page 8 of 9
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105715
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/09/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hampton Court Nursing and Rehabilitation Center
16100 NW 2nd Avenue
North Miami Beach, FL 33169
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 0759
The medications were administered one hour and forty-seven minutes after their scheduled time.
Level of Harm - Minimal harm
or potential for actual harm
A review of admission records indicated Resident #305 was last admitted on [DATE] with diagnoses
including osteoarthritis of hip, fracture of left toe, fall, pain, type 2 diabetes mellitus, hypertension, and
Atherosclerotic heart disease.
Residents Affected - Few
An interview was conducted with Staff B, LPN on 11/8/22 at 12:31 p.m. Staff B stated Resident #305's
medications were in the medication cart; she was late giving them because she had a lot of medications to
give. Staff B stated she has to give all the residents their medications and also give pain medications or
things people ask for in between giving the scheduled medications. Staff B stated she knows medications
should be given one hour before or after the time they are ordered; with all the back and forth they are
sometimes late. Staff B confirmed the provider was not notified.
An interview was conducted on 11/8/22 at 2:47 p.m. with the facility's Director of Clinical Services. She
stated their policy is medications are given one hour before or after the time scheduled unless the resident
refuses or requests something different. Sometimes staff stretch it a little depending on the medication if
there is a good reason, but if they are late the nurse should call the provider.
Review of the facility's policy revealed a facility policy titled Medication Administration-General Guidelines,
dated January 2019 was reviewed. The policy stated the following:
A. 4- Prior to administration, the medication and dosage schedule on the resident's medication
administration record (MAR) is compared with the medication label. If the label and MAR are different and
the container is not flagged indicating a change in directions or if there is any other reason to question the
dosage or direction, the physician's orders are checked for the correct dosage schedule.
B. 2- Medications are administered in accordance with written orders of the attending physician.
B. 10- Medications are administered within 60 minutes of scheduled time, except before or after meal
orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine
medications are administered according to the established medication administration schedule for the
facility.
A facility policy titled Medication Orders, dated 5/25/22, was reviewed. The policy stated the following:
1. Medications should be administered only upon the signed order of a person lawfully authorized to
prescribe.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105715
If continuation sheet
Page 9 of 9
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
FAQ · About this visit
Common questions about this visit
What happened during the November 9, 2022 survey of HAMPTON COURT NURSING AND REHABILITATION CENTER?
This was a inspection survey of HAMPTON COURT NURSING AND REHABILITATION CENTER on November 9, 2022. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HAMPTON COURT NURSING AND REHABILITATION CENTER on November 9, 2022?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.