Inspection·June 6, 2024

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 06/14/2024 FORM APPROVED OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION A. BUILDING (X3) DATE SURVEY COMPLETED 106047 B. WING R 06/06/2024 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 SUMMARY STATEMENT OF DEFICIENCIES ID PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE [F 000] INITIAL COMMENTS [F 000] An unannounced revisit to the Recertification survey, was conducted on 06/06/24 at Life Care Center of Inverrary. The facility is in compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 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: KL5H12 Facility ID: 35960976 If continuation sheet Page 1 of 1 PRINTED: 06/14/2024 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: __________ B. WING ______ (X3) DATE SURVEY COMPLETED 35960976 R 06/06/2024 NAME OF PROVIDER OR SUPPLIER LIFE CARE CENTER AT INVERRARY 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 (N 000) INITIAL COMMENTS (N 000) An unannounced revisit to the Relicensure survey, was conducted on 06/06/24 at Life Care Center of Inverrary. The previously cited deficiencies were found corrected at the time of the survey. AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed STATE FORM 6809 KL5H12 If continuation sheet 1 of 1