Inspection·May 20, 2024

PRINTED: 05/22/2024 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35960976 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 05 - MAIN LIC B. WING _ (X3) DATE SURVEY COMPLETED R 05/20/2024 NAME OF PROVIDER OR SUPPLIER LIFE CARE CENTER AT INNERRARY STREET ADDRESS, CITY, STATE, ZIP CODE 4300 ROCK ISLAND ROAD LAUDERHILL, FL 33319 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X6) COMPLETE DATE [K 000] INITIAL COMMENTS [K 000] An unannounced Fire & Life Safety Relicensure revisit survey was conducted on 05/20/2024 at Life Care Center at Innerrary, a nursing home in Lauderhill, Florida. This was a follow-up to the annual Fire & Life Safety survey completed on 04/16/2024. All previously cited Fire & Life Safety deficiencies were corrected. AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X8) DATE Electronically Signed 05/21/24 STATE FORM 6809 KL5H22 If continuation sheet 1 of 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 05/22/2024 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED R 106047 B. WING 05/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LIFE CARE CENTER AT INVERRARY 4300 ROCK ISLAND ROAD LAUDERHILL, FL 33319 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE [K 000] INITIAL COMMENTS [K 000] An unannounced Fire & Life Safety Recertification revisit survey was conducted on 05/20/2024 at Life Care Center at Innerrary, a nursing home in Lauderhill, Florida. This was a follow-up to the annual Fire & Life Safety survey completed on 04/16/2024. All previously cited Fire & Life Safety deficiencies were corrected. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 05/21/2024 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 of survey these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KL5H22 Facility ID: 35960976 If continuation sheet Page 1 of 1