Wilton Manors Healthcare & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Wilton Manors Healthcare & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF684Jun 19, 2025

  Based on review of policy and procedure, record review and interview, the facility failed to ensure that residents received appropriate care and treatment to prevent an evolving change in condition and status for 1 of 1 sampled resident reviewed, Resident #113. The findings included: Review of the facility policy, titled, Change in a Resident's Condition or Status, provided the Director of Nursing (DON), revised May 2017, documented in the Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and the representative (sponsor) of changes in the resident's medical / mental condition and/or status (e.g. changes in level of care, billing / payments, resident rights, etc.). Policy Interpretation and Implementation: 1. […]

• No harm, potential for more than minimal, widespreadF812Sep 17, 2021

  Based on observations and interviews, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included failure to maintain equipment in safe working conditions and failure to maintain sanitary conditions. The findings included: During a tour of the kitchen conducted on 09/14/21 at 8:52 AM, accompanied by the Certified Dietary Manager (CDM), the following were noted: 1. Several small, black flying pests were observed in the dishwashing area. The CDM acknowledged the surveyor's findings and stated that the pests probably came in through the door in the dishwashing area (which was left open for incoming meal carts at the time of the tour). 2. […]

• No harm, potential for more than minimal, patternF805Jun 19, 2025

  3. Review of the American Dietetic Association titled National Dysphagia Level 2: Mechanically Altered Nutrition Therapy showed the following: for vegetables, it is recommended to be soft, well cooked, should be less than 1/2 inch, and easily mashed with a fork. 3a. Record review revealed Resident #230 was admitted to the facility on [DATE] with diagnoses of Unspecific Protein-Calorie Malnutrition, Unspecific Dementia, and Muscle Weakness. On 06/16/25 at 12:44 PM, an observation was conducted, during which Resident #230 was noted in her room eating her lunch meal, being assisted by staff. The meal ticket listed the following: a mechanically altered ground diet with pureed fruits and vegetables, collard greens, macaroni and cheese, a dinner roll, ground ham, and banana pudding. […]

• No harm, potential for more than minimal, patternF812Jun 19, 2025

  Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and sanitary conditions and to prevent foodborne illnesses during two of the two visits to the main kitchen. The findings included: Review of the US Food and Drug Administration's (FDA) report, dated March 2022, showed the following: raw hamburger, ground for 1-2 days, and fresh poultry, stored for 1-2 days, in the refrigerator. Website: https://www.fda.gov/food/people-risk-foodborne-illness/refrigerator-freezer-chart-food-safety-moms-be. On 06/16/25 at 8:55 AM, during tour and observation in the kitchen, the following were noted: a. […]

• No harm, potential for more than minimal, patternF550Dec 8, 2022

  Based on observation and interview, it was determined the facility failed to treat 3 of 3 sampled residents, Resident's #95, #105,and #281, and potentially 132 facility residents, with respect and dignity in a manner that promotes enhancement of quality of life that includes providing drinking cups and glasses with meals. The findings included: During the observation of the lunch meal of 12/05/22, breakfast meal of 12/06/22, and lunch meal of 12/06/22, it was observed that all residents who received beverages in disposable cartons, including milk, thickened milk, juice and supplements, did not receive a drinking cup for the cartons' beverages. Specifically, the facility residents were required to drink straight from the disposable cartons. […]