Cycle 1
Health 2025-03-06 · Fire 2025-03-06
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Pompano Beach, FL
Deerfield Beach Health And Rehabilitation Center
3-star overall rating with 3-star inspections with $36,089 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
401 East Sample Road, Pompano Beach, FL
(954) 941-4100
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
194
Certified beds
Average residents
183
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Florida Institute For Long-Term Care
Operator or chain grouping
Approved since
1988-10-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
18 facilities
Chain averages 2 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.82
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.32
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.88
CMS adjusted RN staffing hours
Adjusted total hours
3.56
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,981
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.71
Baseline 22.92% · Performance 22.21% · Measure score 0.71 · Achievement 0 · Improvement 0.71
Healthcare-associated infections
0
Baseline 7.39% · Performance 12.25% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
8.32
Baseline 39.87% · Performance 29.65% · Measure score 8.32 · Achievement 8.32 · Improvement 6.30
Adjusted total nurse staffing
1
Baseline 3.42 hours · Performance 3.36 hours · Measure score 1 · Achievement 1 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.42% |
10.72%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 109 · Observed rate 19.27% · Lower 95% interval 9.58% |
| Discharge to community | 40.49% |
50.57%
10.1 pts worse
|
No Different than the National Rate · Eligible stays 88 · Observed rate 28.41% · Lower 95% interval 30.34% |
| Medicare spending per beneficiary | 1.25 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.23% |
95.27%
4 pts better
|
Numerator 129 · Denominator 130 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 130 |
| Discharge self-care score | 47.56% |
53.69%
6.1 pts worse
|
Numerator 39 · Denominator 82 |
| Discharge mobility score | 32.93% |
50.94%
18 pts worse
|
Numerator 27 · Denominator 82 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 130 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 12.25% |
7.12%
5.1 pts worse
|
Worse than the National Rate · Eligible stays 57 · Observed rate 26.32% · Lower 95% interval 7.78% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 225 |
| Staff flu vaccination coverage | 9.09% |
42%
32.9 pts worse
|
Numerator 18 · Denominator 198 |
| Discharge function score | 59.76% |
56.45%
3.3 pts better
|
Numerator 49 · Denominator 82 |
| Transfer of health information to provider | 98.11% |
95.95%
2.2 pts better
|
Numerator 52 · Denominator 53 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 6.56% |
25.2%
18.6 pts worse
|
Numerator 4 · Denominator 61 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.3% |
2.6%
2.3 pts better
|
3.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.0% · Q4 0.6% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.4% |
5.9%
1.5 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.2% · Q3 4.0% · Q4 4.9% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
15.7%
2.7 pts worse
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.9% · Q2 20.5% · Q3 16.2% · Q4 16.9% · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.9% |
9.8%
2.1 pts worse
|
16.7%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 8.7% · Q3 12.4% · Q4 18.3% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.8% |
11.7%
5.9 pts better
|
16.3%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 10.2% · Q3 3.4% · Q4 5.5% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.9% |
9.8%
1.9 pts better
|
14.9%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 8.8% · Q3 6.8% · Q4 7.1% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
0.4%
0.3 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.5% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 1.8% |
12.5%
10.7 pts better
|
19.8%
18 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.9% · Q3 1.2% · Q4 0.0% · 4Q avg 1.8% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.1%
0.2 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 6.9% · Q3 5.7% · Q4 5.5% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
94.3%
5.1 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.1% · Q3 99.1% · Q4 99.5% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
9.3%
1.6 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 8.8% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.5%
1.5 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.8% · Q3 2.9% · Q4 2.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.1% |
94.7%
4.4 pts better
|
79.7%
19.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.6% |
26.2%
2.4 pts worse
|
23.9%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.6% · Observed 31.2% · Expected 26.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-09 · Fire 2023-11-09
11 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-07-21 · Fire 2022-07-21
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-03-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-07
F · Potential for more than minimal harm
2025-03-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-07
D · Potential for more than minimal harm
2023-11-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-12-08
D · Potential for more than minimal harm
2022-07-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-18
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2026-02-09
E · Potential for more than minimal harm
2025-03-06
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-04-06
D · Potential for more than minimal harm
2024-11-13
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-12-23
G · Actual harm
2023-11-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-09
G · Actual harm
2023-11-09
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-12-09
D · Potential for more than minimal harm
2023-11-09
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-12-09
D · Potential for more than minimal harm
2023-11-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-09
D · Potential for more than minimal harm
2023-11-09
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-12-09
D · Potential for more than minimal harm
2023-11-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-12-09
D · Potential for more than minimal harm
2023-11-09
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-12-09
D · Potential for more than minimal harm
2023-11-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-09
D · Potential for more than minimal harm
2023-11-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-09
D · Potential for more than minimal harm
2023-11-09
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2023-12-09
E · Potential for more than minimal harm
2022-07-21
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-08-17
E · Potential for more than minimal harm
2022-07-21
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-21
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-21
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-21
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-08-17
Penalties and ownership
What sits behind the stars
$36,089
2023-11-09
Fine
Fine · fine $36,089
Fine
Ownership
Fi-Broward Nursing, LLC
5% Or Greater Direct Ownership Interest · Organization
Florida Institute For Long Term Care LLC
5% Or Greater Indirect Ownership Interest · Organization
Anu Health Management LLC
Operational/Managerial Control · Organization
Consulting Support Services, LLC
Operational/Managerial Control · Organization
Facey, Reita
Operational/Managerial Control · Individual
Facility Support Company, LLC
Operational/Managerial Control · Organization
Jaffe, Howard
Corporate Officer · Individual
Kane Financial Services, LLC
Operational/Managerial Control · Organization
Katz-Hall, Kathy
Corporate Officer · Individual
Mullarkey, James
Corporate Officer · Individual
Richmond, Penny
Corporate Officer · Individual
Thomas, Antonio
Operational/Managerial Control · Individual
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#3
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