South Dade Nursing and Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record reviews, the facility had failed to obtain admission orders for a medicated patch for one (Resident #175) out of three sampled newly admitted residents. Resident #175 had an undated medicated patch that the resident reported was for hypertension on the left shoulder but there was no corresponding physician's order in the resident's clinical records, which noted orders for oral hypertensive medications that the resident had been receiving since admission. This deficient practice could have caused severe hypotensive reactions for Resident #175, who had been admitted from the hospital to the facility six days earlier. At the time of the survey, 166 residents resided in the facility. Observation on 12/09/25 at 11:20 AM revealed an undated patch on Resident # 175's left shoulder. (photo evidence) Upon interview, Resident#175 stated: [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide an environment free of accident hazards for one (Resident#156) out of one sampled resident as evidenced by an observation of Resident #156 in bed unattended while the bed was in a high position. There were 166 residents residing in the facility at the time of survey.

Inspectors wroteBased on record reviews observations and interviews, the facility stored drugs and biologicals contrary to professional standards. Specifically, one out of three medication rooms had expired medical supplies; two out of six medication carts had loose pills, and medications were found at the bedsides of two out of 166 residents who resided in the facility during the survey.

Inspectors wroteBased on observations, record review and interview the facility failed to ensure accuracy in providing medications to meet needs for three residents (Resident #121, Resident #95 and Resident #163) out of 17 sampled residents as evidenced by three medication omissions noted during medication administration observation. There were 179 residents residing in the facility at the time of survey. The findings Included: On 07/24/2024 at 08:31 AM a medication administration observation was made on the second floor, [NAME] medication cart with Staff H, Licensed Practical Nurse (LPN) for Resident #121. During medication administration Staff H, LPN dispensed one (1) Calcium 500 plus vitamin D chewable tablet into the medication cup. [...]

Inspectors wroteBased on observations, interview and record review, the facility's quality assurance and assessment committee failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem areas related to repeated deficient practice for F755 Pharmacy Services and Procedures and F867 QAPI-QAA Improvement Activities .These repeated deficient practices has the potential to affect any of the 179 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed ensure two residents (Resident #142, Resident #117) out of two residents observed during dining were treated with respect and dignity, as evidenced by staff member observed standing while feeding the residents. This facility's deficient practice has the potential to affect any of the 114 residents residing in the facility that required assistance from staff with eating.

Inspectors wroteBased on record review and interview the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASRR) was completed accurately prior to admission and failed to revise the screening following admission for one resident (Resident #63) out of 17 sampled residents. There were 179 residents residing in the facility at the time of the survey. The findings Included: Record Review of Resident #63's Level I PASRR (Preadmission Screening and Resident Review) documented Section I: PASRR Screen Decision Making: A: MI (Mental Illness) or suspected MI (check all that apply) - Anxiety and Major Depressive disorder checked off. Findings based on documented history were-Section II Other indicators for PASRR screening Decision-Making: All checked no. Does individual have validating documentation to support dementia or related neurocognitive disorder - no. [...]

Inspectors wroteBased on observations, record review and interview the facility failed to follow the care plan for two residents (Resident #102 and Resident #72) as evidenced by observations of Resident #102 in bed with full length siderails and observation of Resident # 72 in bed with one full length of two full length padded siderails in the down position while in bed. There were 179 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide a safe environment for two residents (Resident #43 and Resident #72) out of 17 sampled residents as evidenced by an observation of Resident #43 with smoking materials while not in the designated smoking area. There were 26 residents that smoked residing in the facility that smoked. Observation of one resident (Resident #72) out of two residents reviewed for side rails was noted with one of two full lengths bilateral padded siderails in the down position while in bed and unattended by staff. There were 179 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observations, record review and interviews the facility failed to administer oxygen therapy at the prescribed rate for one resident (Resident # 26) out of two residents reviewed. As evidenced by observations of Resident # 26 receiving oxygen via nasal cannula at 3 Liters Per Minute (LPM). There were 14 residents residing in the facilty that are require oxygen therapy.

Inspectors wroteBased on observations, record review and interview the facility failed to have a medication error rate below 5% as evidenced by three medication omissions out of 25 medications administration opportunities. There were 179 residents residing in the facility at the time of survey. On 07/24/2024 at 08:31 AM a medication administration observation was made on the second floor, [NAME] medication cart with Staff H, Licensed Practical Nurse (LPN) for Resident #121. During medication administration Staff H, LPN dispensed one (1) Calcium 500 plus vitamin D chewable tablet into the medication cup. Record review of Electronic Medication Administration Record (EMAR) revealed Resident #121 physician order dated 5/29/2023 for Oyster Shell Calcium/Vitamin D Tablet 500-200 Milligram (mg) per Unit directions- give 1 tablet by mouth two times a day for SUPPLEMENT. [...]

Inspectors wroteBased on observations, record review and interview the facility failed to properly store medications and biologics for two residents out of 17 sampled residents as evidenced by observations of medication at the bedside of Resident #62 and Resident #373 and unattended pills in a medication cup on top of second floor's East Medication cart. There were 179 residents residing in the facility at the time of survey. The findings Included: On 07/21/2024 at 10:38 AM a tube labeled Hydrocortisone 1/2 % cream observed on side table and a bottle of normal saline solution on Resident#62's nightstand (photo evidence) The surveyor notified the 7:00 AM-3 :00 PM supervisor, Registered Nurse (RN) and Staff D, Licensed Practical Nurse (LPN). All entered room together. [...]

Inspectors wroteBased on observations, record review and interview the facility failed to meet infection control standards for one resident (Resident #30) out of 17 sampled residents as evidenced by an observation of an unchanged Intravenous dressing. There were 179 residents residing in the facility at the time of the survey.

Inspectors wroteResident #9 On 3/06/2023 at 4:00 AM, upon entering the third-floor dining room. Resident # 9 was observed asleep in a recliner with the footrest propped up by a dining room chair, between a wall and a column/pillar. (Photographic and video evidence) In an interview conducted on 03/06/2023 at 4:11 AM Staff E, a Registered Nurse (Night Supervisor). Was asked why the residents were sleeping in the dining room. Staff E stated The residents are alone in the room; they try to get out of bed. The nurse will bring them here to guarantee that they are not falling. We bring them all in one area. When asked if this was the normal routine? Staff E stated No, it's only if I don't have enough CNAs (Certified Nursing Assistants). I have four CNAs on the floor. These residents are getting out of bed and at risk of falling. We have tried non-pharmacological interventions. [...]

Inspectors wroteResident #9 In an observation conducted on 3/06/23 at 4:00 AM, upon entering 3rd floor dining room. Resident # 9 was observed asleep in a recliner with the footrest propped up by a dining room chair. Resident 9 was noted to be wedged between a wall and a column/pillar. In an interview conducted on 03/06/23 at 4:11 AM Staff E, a Registered Nurse (Night Supervisor). Was asked why the residents were in the dining room. Staff E stated The residents are alone in the room; they try to get out of bed. The nurse will bring them here to guarantee that they are not falling. We bring them all in one area. When asked if this was the normal routine? Staff E stated No, it's only if I don't have enough CNAs (Certified Nursing Assistants). I have four CNAs on the floor. These residents are getting out of bed and at risk of falling. We have tried non-pharmacological interventions. [...]

Inspectors wroteBased on observation, interview, the facility's administration failed to implement and provide services effectively and efficiently related to ensuring safety measures were in place to prevent negligence and ensure residents are free from restraints and receive the highest practicable quality of care. The facility ' s administration failed to ensure adequate interventions for supervision was assigned to ensure the safety of residents. The facility's administration failed to ensure incontinence care, positioning and implement appropriate and dignified levels care to meet residents identified needs. This affected 8 out 8 sampled residents (Resident #9, #52, #63, #81, #112, #127, #172, #428) observed in the 3rd dining room at 4:00AM on 3/6/2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedures on abuse by not filing the immediate report within the required time of two hours related to allegations of abuse and neglect. As evidenced by at 4:00 AM during initial tour the survey team observed seven residents (Resident # 9, Resident #63, Resident # 127, Resident # 112, Resident #172, Resident #428 and Resident #81) sleeping in recliners and one resident (Resident # 52) seated in a wheelchair in the 3rd floor dining room out of eight residents who were reviewed for abuse. This facility practice had the potential to have a negative impact on the health and safety of all 176 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F609 Reporting of Alleged Violations related to the facility failed to implement their policy and procedures on abuse by not filing the immediate report within two hours for allegations of abuse observed by survey team of seven residents (Resident # 9, Resident #63, Resident # 127, Resident # 112, Resident #172, Resident #478, Resident #81) sleeping in recliners and one resident (Resident # 52) seated in a wheelchair in the third floor dining room, out of eight residents whose abuse report were reviewed. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the dishwashing machine was operating properly. This has the potential to affect 160 out of 176 residents who reside in the facility at the time of survey.

Inspectors wroteBased on observation, interview, and record review the facility failed implement its facility grievance protocol to address and resolve a concern voiced by one resident (Resident #125) out of three residents reviewed. As evidenced by the facility's failure to assist Resident #125 who requested assistance to communicate with her son.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure pharmaceutical services and procedures were being followed for one (2nd Floor East Cart) out of three medication carts observed of the six medication carts in the facility.