Health inspection·November 20, 2023

F 0610 was kind of off the patient trach. Level of Harm - Minimal harm or potential for actual harm Review of Nurses Notes revealed no notes were written by the nursing staff surrounding the event. One Nurses Note was written on 10/17/23 at 7:10 PM which stated Call placed to mother of resident. Voicemail left as there was no response. A Medication Administration Note was written on 10/18/23 at 10:01 AM which stated hospitalized with no additional information documented. Residents Affected - Few An interview was conducted with the facility's Risk Manager on 11/20/23 at 11:23 AM. She stated she was out of town during the week of the event and that she did not begin her investigation until she returned to the facility on [DATE]. When asked if she had reviewed the nursing notes during her investigation, she stated she, as the risk manager, does not review notes during her investigation, that it is the Director of Nursing's responsibility to conduct a clinical investigation. She stated when she returned to work following the event, she received notes and statements that had been collected by the facility's Administrator following the event. She recalled a [NAME] County [NAME] Officer (BSO) notified the facility that Resident #1 had passed away while at the hospital. An interview was conducted with the facility's Administrator on 11/20/23 at 11:29 AM. She stated her investigation included collecting witness statements and timelines from the beginning of the shift on 10/17/23. She said in her investigation, she decided to send the pulse ox machine and ventilator back to the companies for event traces to be downloaded. She said this would assist her in finding out if there was a machine malfunction. However, at the time of this survey, 11/20/23, she had not received this information from either company. She stated this was why her investigation was ongoing. An interview was conducted with the facility's Director of Nursing (DON) on 11/20/23 at 2:27 PM. She stated she was new to the facility and that she started after Resident #1's event. She stated the previous DON had done a partial investigation and that she had continued with her own investigation of the event. She stated that she had conducted in-services with the staff and that a drill had been done with the staff as well. The surveyor asked her if any mock code drills had been done with the staff and she said yes, one mock code had been done. When asked if she felt that one mock code drill in a month since the incident was sufficient for the staff, she stated, no and then also said it's a work in progress. An interview was conducted with the facility's Administrator on 11/20/23 at 2:30 PM. She stated the previous DON had conducted a table-talk type of in-service with the staff the day following the event. She stated they initially were waiting for Resident #1 to return to the facility but that on 10/24/23, a Child Protective Services investigator and a [NAME] County [NAME] arrived at the facility to conduct an investigation. She stated, I wasn't even going to report it to AHCA until they arrived, then I figured AHCA would want to know. She stated the ventilator went with Resident #1 to the hospital and she was unable to retrieve the ventilator from the hospital until 10/27/23. She said that she then contacted the ventilator company to have the data analyzed. When asked if a Root Cause Analysis was completed, she stated the surveyors would have to talk to the Risk Manager who had already left the facility for the day. She stated that herself, the Risk Manager, the current and the previous DONs, and the Medical Director had all performed investigations regarding this event along with the Child Protective Services investigator and the [NAME] County [NAME]. The surveyor explained that the concern was that so many investigations were being conducted but that none had been completed and none had concluded what the root cause of the event was. When asked if she could provide the investigations conducted by the others, she did not respond. A telephone interview was conducted with the facility's Risk Manager on 11/20/23 at 4:14 PM. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 2 of 3 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 106110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Childrens Comprehensive Care Center Inc 200 SE 19th Avenue Pompano Beach, FL 33060 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 0610 confirmed that a Root Cause Analysis was not completed and that she was still waiting for the data download information from the ventilator company before she could finalize her investigation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106110 If continuation sheet Page 3 of 3