F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of policy and procedure, interview, observation and record review, the facility failed to notify the
resident's representative regarding a change in skin condition, for 1 of 3 sampled residents observed
(Resident #1).
The findings included:
Review of the facility policy and procedure titled, Change in a Resident's Condition or Status, which was not
dated, and provided by the Director of Nursing (DON), included: Our facility shall promptly notify the
resident, his or her attending physician, and representative (or sponsor) of changes in the resident's
condition and/or status. The nurse supervisor will record in the resident's medical record any changes in the
resident's medical condition or status.
Review of the facility policy and procedure titled, Trach Care, dated 02/2025, included: Prevention is the
best medicine for the care of the skin around the trach and the neck. Meticulous care should be taken to
assess the skin each shift and document findings. Skin care management plans should be initiated when
the skin condition is less than optimal .
Review of the facility policy and procedure titled, Pressure Ulcer Prevention and Managing Skin Integrity,
dated 09/2023 included: Nursing, in collaboration with the health care team, will assess and manage skin
integrity for all residents. Risk for pressure ulcer development will be evaluated upon admission. Skin
inspections will be completed on admission and daily for all residents. Purpose: To promote prompt
evaluation and intervention of any changes in skin integrity. The focus of the examination will be on the skin
over the bony prominence and in skin fold/creases. Findings will be documented in the patient medical
record (paper or electronic). Communication to the provider and other caregivers of a skin breakdown is
essential.
1) Resident #1 was originally admitted to the facility on [DATE] with the following diagnoses which included:
Disruption of Wound, , Cerebral Palsy, Hypertension, Epilepsy, Hypoplastic Right Heart Syndrome, Double
Outlet Right Ventricle, Aphasia and Chronic Respiratory Failure. Resident #1 is medically fragile with a
Ventilator and Tracheotomy in place and totally dependent on staff for care, nutrition and hydration. She had
a Brief Interview Mental Status (BIMS) indicative of (severe impairment).
During an interview conducted on 05/01/25 at 4:09 PM with the resident's mother, she verbalized that, on
Friday 04-11-25 she went to visit Resident #1 and that's when she noticed that she had a hole/bedsore on
the right side of her neck, which she described as having the smell of eggs and sewage
(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 3
Event ID:
106110
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
05/02/2025
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
and was the size of a golf ball and deep. The mother indicated that she had spoken to the wound care
doctor in the facility the same day and was told by him that Resident #1 also had sores on her neck, in the
past, which she started getting in 2024. According to the mother, this was the first time that she heard
anything about Resident #1 having sores on her neck. The mother went on to say that the staff members
have her phone number, but hadn't called her at all, regarding this. The complainant ended by saying that
the doctor apologized for not calling.
On 05/02/25 at 10 AM an observation was conducted of Resident #1 who was resting in bed with her head
elevated and with both her Ventilator and Tracheotomy in place. Resident #1 was not observed as having a
hole/bedsore on the right side of her neck. The resident's neck did not smell like eggs and sewage.
However, it was apparent from the two (2) healed, old discolored scars on the back and right side of the
resident's neck that a former wound or sore, that had been treated and healed. Resident #1's mouth and
teeth were clean, with no build-up, noted, at the time, and she was wearing her hand splints. (Photographic
Evidence Obtained).
Record review of the Resident #1's Tracheotomy Care plan initiated 03/07/19 indicated Focus: Resident #1
has Tracheotomy related to disease process. Interventions: Ensure that Trach ties are secured at all times
.Trach care Q shift, cleanse neck with normal saline, inspect skin for any abrasion or redness, apply A & D
as needed. Goal: Resident #1 will have no abnormal drainage around Trach site and will have no signs or
symptoms of infection through review date.
Record review of the Resident #1's Ulceration or Interference Care plan initiated 03/27/24 indicated Focus:
Structural integrity of layers of skin to the right side of her neck caused by prolonged pressure related to:
Trach collar and excess secretion. Interventions .Document on daily flow sheet: if skin is intact, mark Y. If
skin is reddened or has open area; mark N. Report any new openings to Registered Staff Goal: There will
be a reduction in size/stage of pressure ulcer and no signs of infection or complication during period of
review.
On 04/22/25 the Wound Care Doctor's Wound Evaluation documented that, .Patient has a Stage IV wound
on her right lateral neck .pressure, duration (>) greater than twenty-two (22) days Wound size 1.0 x 1.2 x
0.2 cm Surface area 1.20 cm2, edges attached, moderate serous exudate, 100% granulation tissue, pain
noted with grimacing, no signs of infection. Dressing Treatment Plan: Mepilex silicone Ag+ foam apply
Q-shift and as needed if saturated, soiled, or dislodged. For nine (9) days secure under Trach strap.
Computerized record review conducted of a late entry nursing note by Staff A, a Licensed Practical Nurse
(LPN) in which he revealed that, on Friday 04/11/25 around 5:30 PM resident's mother came in to visit her
daughter . She complained about wound she observed on the resident's neck. The Respiratory Therapist
(RRT) explained to her that the physician was notified and ordered Tracheotomy care which included
Mepilex to tracheotomy site twice a day. Resident's mother was informed about it, at that time.
During an interview and side-by-side computerized record review conducted on 05/02/25 at 1:35 PM with
Staff A, he revealed that neither he, nor any other nursing staff members, had recorded any documentation
in the nurses' progress notes, prior to Friday 04/11/25, to indicate that he or they had spoken with the
mother about any of the details, regarding Resident #1's current skin condition.
A side-by-side record review was conducted with the DON in which it was noted that there was no
documentation recorded in any of the Respiratory Therapists' notes, nurses' progress, the Dietary
(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
05/02/2025
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Nutrition notes (12/31/24, 01/08/25, 02/26/25 and 03/30/25), nor in the Care Plan meetings (01/08/25 and
04/09/25) and Transitional meeting (03/06/25), from 12/31/24 until Friday 04/11/25 (when the complainant
entered the facility to discover her child's wounds herself), to specifically describe, in detail, the resident's
current skin condition. Nor was there any documentation to describe the presence of any wounds. There
was not any documentation to signify whether or not the resident's representative had been previously
contacted and notified of the resident's current and on-going wound status , by the facility's nursing staff.
The computerized last Skin Evaluation completed (prior to 04/11/25) had been dated 10/12/24.
2) Record review conducted for last year, 2024, also revealed that Resident #1 had developed a wound to
her neck, which had been documented as treated and healed.
However, there had still been no notation anywhere in the record to show that the resident's representative
had been notified of this change in skin condition with treatment, between the dates of 03/28/24 until
04/23/24.
A subsequent interview and side-by-side computerized record review was conducted on 05/02/25 at 4:57
pm with Staff A, one (1) of three (3) currently available staff members, who had also been working in the
facility during dates of service (DOS) 03/28/24 until 04/23/24, regarding his nursing note entry on 04/12/24
at 08:05 AM. Staff A, acknowledged and revealed that neither he, nor any other facility nursing staff
members, had made any documentations in the record of Resident#1's current skin condition at that time.
Neither, had he made any contact with the resident's representative concerning such.
The DON further recognized and acknowledged on 05/02/25 at 5:05 PM that the resident's representative
should always be notified or contacted for any changes to the resident's skin status or condition.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106110
If continuation sheet
Page 3 of 3