Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Biscayne Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found multiple medicated ointments and topical solutions left at the bedside instead of in locked storage, including Diclofenac on a sink, a hydrophilic wound dressing in a basket on a nightstand for a severely cognitively impaired resident, and Ciclopirox solution on another nightstand. Facility policy requires all drugs and biologicals to be stored in locked compartments, and staff, including an LPN, the wound care nurse, and a CNA, stated that medications and ointments are to be kept on locked carts and not in resident rooms, yet these items remained accessible in resident rooms in violation of that policy.
A resident with peripheral vascular disease and a Stage 4 pressure ulcer had a physician’s order for Tramadol to be given on the day shift 30 minutes before wound care, consistent with the care plan and the facility’s pressure ulcer protocol requiring pain assessment and documentation. Review of the MAR for one month showed multiple missing nurse signatures for this ordered pain medication and several entries marked “out of parameters” by an RN without any corresponding progress notes, while the Treatment Record showed that daily wound care was performed. During observed wound care the resident denied pain, and the Wound Care Nurse reported she checks the MAR to verify medication administration, while the DON stated nurses must follow physician orders and document refusals, highlighting that the medical record did not contain complete and accurate documentation of the ordered pre-wound-care pain medication.
Surveyors identified multiple failures to maintain a safe environment, including a razor left on a sink in a cognitively intact resident’s room, that resident’s personal razors stored in a nightstand despite facility rules prohibiting razors in rooms, an LPN discarding unused lancets into regular trash instead of a sharps container after a blood glucose check, and unattended housekeeping carts on an upper floor with germicidal wipes left on top and easily accessible, contrary to facility policy requiring chemicals to be locked in cart compartments.
Surveyors found that the facility failed to keep the environment free of accident hazards when a resident’s room contained an unattended shaving razor on the sink and additional razors in a nightstand, despite leadership stating razors were not permitted in resident rooms. An LPN disposed of unused lancets in regular trash instead of a sharps container, contrary to acknowledged policy. On two occasions, an unattended housekeeping cart on an upper floor had germicidal wipes left on top and easily accessible, even though housekeeping leadership and staff stated that chemicals and disinfectant wipes were to be kept locked in the cart for safety.
Surveyors found that the facility failed to follow its own medication storage policy when medicated ointments and solutions were left unsecured in several resident rooms. A resident with heart failure had Diclofenac ointment on the sink, another resident with bladder cancer had Ciclopirox topical solution on the nightstand, and a severely cognitively impaired resident with a history of cerebral infarction had hydrophilic wound dressing stored in a bedside basket on multiple observations. Staff, including an LPN, a wound care nurse, and the ADON, stated that medications and ointments were supposed to be kept on locked carts and not at the bedside, and that residents were not permitted to keep medications in their rooms, demonstrating noncompliance with the facility’s written storage policy and federal requirements.
A resident with a Stage 4 pressure ulcer and a physician’s order for Tramadol 50 mg to be given on the day shift 30 minutes before wound care had multiple missing and unexplained entries on the MAR, even though the Treatment Record showed that wound care was performed daily. On several days, there were no nurse signatures for the ordered Tramadol, and on other days the MAR was marked as “out of parameters” without any supporting progress notes. The wound care nurse reported relying on the MAR to confirm that pain medication was given before she performed wound care, and the DON stated that nurses are expected to follow physician orders and document refusals, but the record did not contain adequate documentation to demonstrate proper administration or explanation of the ordered pain medication.
Surveyors found that the facility’s QAPI/QAA program was ineffective in correcting repeated deficiencies related to improper medication storage (F0761). Despite having a written QAPI policy, holding monthly QAA Committee meetings attended by the administrator, DON, medical director, and other department heads, and reporting that direct care staff were invited to participate, the same medication storage deficiency previously cited during an earlier survey recurred. With 94 residents in care, the facility’s QAPI activities did not produce an effective plan of action to resolve and prevent the ongoing medication storage problem.
Surveyors found that a cognitively impaired, functionally dependent resident with aphasia did not have a working bedside call light on multiple observations, and the alternative bell was placed out of reach on top of a mini refrigerator. The resident’s care plan and MDS documented extensive ADL assistance needs and fall/safety precautions. The Maintenance Director reported being unaware of the inoperable call light despite an equipment rounding program, while the Administrator described bedside bells as a matter of resident preference rather than a substitute for a nonfunctional call light. A CNA stated that staff are expected to keep call lights within reach and report malfunctions, and facility policy required fully functional, accessible call devices in resident rooms and bathrooms with regular testing, which was not followed in this case.
The facility failed to ensure accurate administration and documentation of controlled medications for multiple residents. A resident had Alprazolam doses removed from the cart after discontinuation without MAR documentation. Another resident's Clonazepam doses were inconsistently documented. Two residents had Oxycodone/Apap removed without MAR entries, indicating systemic issues in handling controlled substances.
A resident's medications were left unsecured at the bedside, and a medication cart was left unlocked and unattended in a hallway. The resident, who was cognitively intact and unable to self-administer medications, confirmed the nurse left the medications. An LPN admitted to leaving the cart unlocked, violating facility policies.
A resident on dialysis with fluid restrictions was provided with excessive fluids, contrary to physician orders. Despite being aware of her fluid restrictions, the resident received 828 ml of fluids during lunch, exceeding the prescribed 240 ml. Staff interviews revealed a lack of awareness and communication regarding the resident's fluid restrictions, contributing to the deficiency.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a central line, leading to deficiencies in infection control. The resident, receiving IV therapy for chronic osteomyelitis, had no EBP signage outside their room, and staff did not consistently wear appropriate PPE. Observations revealed improper maintenance of IV catheter tubing and inadequate cleaning procedures by an LPN. Interviews with staff and the ADON confirmed lapses in EBP protocol adherence.
Improper Bedside Storage of Topical Medications
Penalty
Summary
The deficiency involves failure to adhere to the facility’s own medication storage policy and state requirements for secure storage of drugs and biologicals. Surveyors observed medicated ointments and topical solutions stored at residents’ bedsides rather than in locked medication storage. On one observation, a container of Diclofenac ointment was found on top of the sink in the room of a resident admitted with heart failure and documented as having no cognitive impairment. In another observation on two separate days, a tube of hydrophilic wound dressing was seen in a basket on the nightstand of a resident admitted with a cerebral infarction due to embolism of the right middle cerebral artery, who was documented as severely cognitively impaired. A third observation found a container of Ciclopirox topical solution on the nightstand of a resident admitted with malignant neoplasm of overlapping sites of the bladder and no cognitive impairment. Record review of the facility’s “Storage of Medications” policy, revised January 2026, showed that all drugs and biologicals are to be stored in locked compartments under proper environmental controls. Staff interviews confirmed that the facility’s practice is that medications and ointments are to be kept on the locked cart and not allowed at the bedside, with staff stating that creams, ointments, and medicated nail polish are to be returned to the treatment cart after use, and that CNAs are to notify nurses if medications are seen in resident rooms. Despite these stated practices, surveyors found multiple medicated products left in resident rooms, demonstrating that medications were not consistently stored in locked or secure areas as required by policy and regulation.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. The facility continues to ensure that all drugs and biologicals are stored appropriately. IMMEDIATE CORRECTIVE ACTION Medications were immediately removed from room for residents #58, #20 and # 29 on 5/11/26. Residents #58, #20 and #29 were not adversely affected by alleged deficient practice. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED All active residents in the facility can potentially be affected by the alleged deficient practice. No residents were adversely affected by the alleged deficient practice. Director of Nursing and/or designee conducted a facility-wide observation audit to ensure that drugs and biologicals are stored appropriately on 05/12/2026. SYSTEMATIC CHANGES The Director of Nursing and/or designee initiated ongoing in-service education with staff on standards of drug and biological storage on 05/20/2026. MONITORINGNursing Supervisor and/or designee will conduct random observation audits to ensure drugs and biologicals are stored appropriately, 5 days a week for 1 month, then weekly for 3 months.The Director of Nursing and/or designee will report findings of observation/audits to the quality assurance committee monthly for 4 months to ensure continued substantial compliance.
Incomplete Documentation of Pre-Wound-Care Pain Medication for Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves incomplete and inadequate medical record documentation for a resident with a pressure ulcer. The resident was admitted with diagnoses including peripheral vascular disease and had a care plan initiated and revised for a pressure ulcer, with interventions directing staff to administer medications and treatments as ordered by the physician. A significant change MDS indicated the resident had no cognitive impairment, required setup/cleanup assistance for eating and oral hygiene, had a Stage 4 pressure ulcer, was on a scheduled pain medication regimen, and experienced moderate, occasional pain in the prior five days. A physician’s order dated 04/23/2026 directed that Tramadol 50 mg be given orally on the day shift for pain, 30 minutes before wound care. Review of the May 2026 Medication Administration Record (MAR) showed missing nurse signatures for the ordered Tramadol on multiple dates, despite the Treatment Record reflecting that wound care was performed daily on the day shift. Specifically, there were no signatures on the MAR for the Tramadol dose on four listed dates, and on several other dates the MAR entries were coded as “out of parameters” by an RN without any associated progress notes explaining these entries. During observation of wound care, the resident denied pain at that time, and the Wound Care Nurse stated she checks the MAR to ensure the pre-wound-care pain medication is given and that she performs wound care Monday through Friday while the floor nurse does it on weekends. The DON stated that nurses are to follow physician orders and document if a resident refuses medication. The facility’s pressure ulcer/skin breakdown protocol required pain assessment and documentation, but the clinical record lacked complete, accurate, and properly documented information regarding administration or non-administration of the ordered pre-wound-care pain medication.
Plan Of Correction
N0101 The facility continues to ensure that resident's medical records are complete and accurately documented. IMMEDIATE CORRECTIVE ACTION Resident #62 was assessed by Director of Nursing upon notification of surveyor and resident# 62 did not have any adverse outcome related to the alleged deficient practice on 5/13/26. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED All active residents in the facility can potentially be affected by the alleged deficient practice. Director of Nursing and/or designee conducted a comprehensive chart audit to ensure that residents with pain medications were accurately documented on EMAR on 5/15/26. No residents were adversely affected by the alleged deficient practice. SYSTEMATIC CHANGES The Director of Nursing and/or designee initiated ongoing in-service education with clinical staff on standards of accurate medication administration documentation with emphasis on accurate documentation of Pain Medication Refusal. MONITORING Nursing Supervisor and/or designee will conduct random observation audits to ensure accurate documentation of pain medication administration and refusal, 5 days a week for 1 month, then weekly for 3 months. The Director of Nursing and/or designee will report findings of observation/audits to the quality assurance committee monthly for 4 months to ensure continued substantial compliance is achieved and maintained.
Failure to Control Razors, Sharps, and Chemical Access in Resident Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and hazard‑free environment on one of two floors, including improper handling of razors, sharps, and chemical products. During an observation, a shaving razor was found on the sink in a resident’s room. The resident, who was cognitively intact with a Brief Interview of Mental Status score of 15/15 and had diagnoses including malignant neoplasm of overlapping sites of the bladder with self‑care deficits related to activity intolerance and generalized muscle weakness, stated the razor on the sink was not his and that he kept his own razors in the nightstand. The LPN initially removed only the razor from the sink and, when questioned by the surveyor about whether residents were allowed to keep razors in their rooms unattended, acknowledged they were not and then returned to remove the razors from the nightstand as well. Facility leadership, including the ADON, Administrator/Risk Manager, and DON, all stated that residents were not allowed to keep shaving razors in their rooms and that razors were to be kept in the supply room. A second deficiency was identified related to improper disposal of sharps. During a blood glucose check for another resident, an LPN discarded unused lancets into the regular trash in the medication cart rather than into a sharps container. When later asked about the facility’s policy and procedure for lancet disposal, the LPN stated that lancets were to be disposed of in a sharps‑resistant container for safety purposes but did not provide an explanation for why the lancets had been placed in the regular trash. The DON stated that nurses were expected to dispose of both used and unused sharps into sharps containers for safety purposes. A third deficiency involved unsecured chemical products on housekeeping carts. On two separate observations on the second floor, a container of germicidal wipes was found left unattended on top of a housekeeping cart in a hallway, with easy access. Corporate housekeeping staff and the facility’s Housekeeping Director stated that the facility had four housekeeping carts and that all chemicals that could harm residents were supposed to be locked in a compartment on the cart, to which housekeeping staff held the key. A housekeeping staff member also stated that disinfectant wipes and cleaning supplies were to be kept locked in the cart for resident safety. These observations occurred despite the facility’s written “Nursing Home Accident Prevention and Safety Policy,” which states the facility is committed to maintaining a safe and hazard‑free environment, preventing accidents and injuries, identifying and correcting safety risks promptly, and requiring all staff to comply with safety procedures and report unsafe conditions immediately.
Plan Of Correction
The facility continues to ensure that the resident environment remains free of accident hazards as possible. IMMEDIATE CORRECTIVE ACTION Resident #29 was not adversely affected by the alleged deficient practice. Razor was immediately removed and disposed of from resident's room by nurse on 5/11/26.Germicidal wipes were immediately secured in a locked housekeeping cart on 5/11/26.Staff E was provided with 1:1 education by Director of Nursing regarding the importance of providing an environment free from hazards and accidents with emphasis on keeping hazardous items like razor secured on 5/11/26.Staff G was provided with 1 to 1 education by House Keeping Director regarding ensuring that all housekeeping chemical products are secured in a locked housekeeping cart when not in use on 5/12/2026.IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTEDAll active residents in the facility can potentially be affected by the alleged deficient practice.The Director of Nursing and/ designee conducted a facility-wide observation audit to ensure that hazardous items are locked and secured and that staff are disposing of Sharps in a Sharp Resistant Container on 05/15/2026.The Housekeeping Director conducted a facility-wide observation on 5/15/2026 to ensure that all housekeeping chemical products were secured and locked inside the housekeeping cart when not in use. No residents were adversely affected by the alleged deficient practice SYSTEMATIC CHANGES Director of Nursing initiated ongoing in-service education with staff on standards of maintaining an environment free from hazards/accidents with emphasis on keeping hazardous items like razor secured and properly disposing of sharps in sharps resistant container on 5/20/26. The Housekeeping Director and/or designee initiated ongoing in-service education on standards of maintaining an environment free from hazards/accidents with emphasis on keeping housekeeping chemical products secured and locked in a housekeeping cart when not in use on 5/20/2026. MONITORING The Director of Nursing and/or designee will conduct random observation audits to ensure that hazardous items are locked and secured and sharps are disposed in sharps resistant container weekly for 3 months. The Housekeeping Director and/or designee will conduct random observation audits to ensure that housekeeping chemical products are secured and locked in a housekeeping cart weekly for 3 months. The Director of Nursing, Housekeeping Director and/or designee will report findings of observation/audits to the quality assurance committee monthly for 3 months to ensure continued substantial compliance is achieved and maintained.
Failure to Control Razors, Sharps, and Chemical Wipes Creating Accident Hazards
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision and safe handling of potentially hazardous items. On one floor, a shaving razor was observed on the sink in a resident’s room. When questioned, the resident stated the razor on the sink was not his and showed the surveyor separate razors he kept in his nightstand. The resident’s record showed admission with malignant neoplasm of overlapping sites of the bladder and care plans for ADL self-care deficits related to activity intolerance, generalized muscle weakness, bladder cancer, and a history of gross hematuria, with interventions including encouraging and assisting with bathing, personal hygiene, and oral care. Facility leadership, including the ADON, Administrator/Risk Manager, and DON, stated that residents were not allowed to keep shaving razors in their rooms and that razors were to be kept in the supply room. Additional observations showed that staff did not consistently follow safe disposal practices for sharps and did not secure chemical products as required by facility policy. An LPN performing a blood glucose check discarded unused lancets into the medication cart trash instead of a sharps container, despite acknowledging that lancets were to be disposed of in a sharps-resistant container. On two separate observations, a housekeeping cart on the second floor was left unattended with a container of germicidal wipes placed on top of the cart and easily accessible. Corporate housekeeping staff and the Housekeeping Director stated that all chemicals that could harm residents should be locked in the cart’s compartment, and housekeeping staff reported that disinfectant wipes and cleaning supplies were to be kept locked in the cart for resident safety. The facility’s written “Nursing Home Accident Prevention and Safety Policy” stated a commitment to maintaining a safe, hazard-free environment and identifying and correcting safety risks promptly.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. The facility continues to ensure that the resident environment remains free of accident hazards as possible. IMMEDIATE CORRECTIVE ACTION Resident #29 was not adversely affected by the alleged deficient practice. Razor was immediately removed and disposed of from resident's room by nurse on 5/11/26. Germicidal wipes were immediately secured in a locked housekeeping cart on 5/11/26. Staff E was provided with 1:1 education by the Director of Nursing regarding the importance of providing an environment free from hazards and accidents with emphasis on keeping hazardous items like razor secured on 5/11/26. Staff G was provided with 1 to 1 education by House Keeping Director regarding ensuring that all housekeeping chemical products are secured in a locked housekeeping cart when not in use on 5/12/2026. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED All active residents in the facility can potentially be affected by the alleged deficient practice. The Director of Nursing and/ designee conducted a facility-wide observation audit to ensure that hazardous items are locked and secured and that staff are disposing of Sharps in a Sharp Resistant Container on 05/15/2026. The Housekeeping Director conducted a facility-wide observation on 5/15/2026 to ensure that all housekeeping chemical products were secured and locked inside the housekeeping cart when not in use. No residents were adversely affected by the alleged deficient practice. SYSTEMATIC CHANGES Director of Nursing initiated ongoing in-service education with staff on standards of maintaining an environment free from hazards/accidents with emphasis on keeping hazardous items like razor secured and properly disposing of sharps in sharps resistant container on 5/20/26. The Housekeeping Director and/or designee initiated ongoing in-service education on standards of maintaining an environment free from hazards/accidents with emphasis on keeping housekeeping chemical products secured and locked in a housekeeping cart when not in use on 5/20/2026. MONITORING The Director of Nursing and/or designee will conduct random observation audits to ensure that hazardous items are locked and secured and sharps are disposed in sharps resistant container weekly for 3 months. The Housekeeping Director and/or designee will conduct random observation audits to ensure that housekeeping chemical products are secured and locked in a housekeeping cart weekly for 3 months. The Director of Nursing, Housekeeping Director and/or designee will report findings of observation/audits to the quality assurance committee monthly for 3 months to ensure continued substantial compliance is achieved and maintained.
Unsecured Medicated Ointments and Solutions Left in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility’s labeling and storage of drugs and biologicals when medicated ointments and solutions were found unsecured in multiple resident rooms on the second floor. During observation, a container of Diclofenac ointment was seen on top of the sink in one resident’s room, and a container of Ciclopirox topical solution was observed on another resident’s nightstand. Both of these residents’ clinical records showed they had no cognitive impairment, with diagnoses including heart failure for one resident and malignant neoplasm of overlapping sites of the bladder for the other. Additional observations showed a tube of hydrophilic wound dressing stored in a basket on a different resident’s nightstand on two separate occasions. Clinical records for this resident indicated admission with a diagnosis of cerebral infarction due to embolism of the right middle cerebral artery and severe cognitive impairment. These findings conflicted with the facility’s written “Storage of Medications” policy, revised January 2026, which states that all drugs and biologicals are to be stored in locked compartments under proper environmental controls. Staff interviews confirmed that medications and ointments were expected to be kept on locked carts and not at the bedside, and that residents were not allowed to keep medications in their rooms, indicating that the observed bedside storage of medicated products did not comply with facility policy and regulatory requirements.
Plan Of Correction
The facility continues to ensure that all drugs and biologicals are stored appropriately. IMMEDIATE CORRECTIVE ACTION Medications were immediately removed from room for residents #58, #20, and #29 on 5/11/26. Residents #58, #20, and #29 were not adversely affected by alleged deficient practice. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED All active residents in the facility can potentially be affected by the alleged deficient practice. No residents were adversely affected by the alleged deficient practice. Director of Nursing and/or designee conducted a facility-wide observation audit to ensure that drugs and biologicals are stored appropriately on 05/12/2026. SYSTEMATIC CHANGES The Director of Nursing and/or designee initiated ongoing in-service education with staff on standards. of drug and biological storage on 05/20/2026. MONITORING Nursing Supervisor and/or designee will conduct random observation audits to ensure drugs and biologicals are stored appropriately, 5 days a week for 1 month, then weekly for 3 months. The Director of Nursing and/or designee will report findings of observation/audits to the quality assurance committee monthly for 4 months to ensure continued substantial compliance.
Incomplete Documentation of Ordered Pain Medication Prior to Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of complete and accurately documented medical records related to pain medication administration prior to wound care for one resident with a pressure ulcer. The resident was admitted with diagnoses including peripheral vascular disease and had a care plan for a Stage 4 pressure ulcer that included administering medications and treatments as ordered. A significant change MDS indicated the resident had no cognitive impairment, required setup/cleanup assistance for eating and oral hygiene, had a Stage 4 pressure ulcer, received a scheduled pain medication regimen, and experienced moderate, occasional pain. A physician’s order dated 04/23/2026 directed that Tramadol 50 mg be given orally on the day shift for pain, 30 minutes before wound care. Review of the May 2026 Medication Administration Record (MAR) showed missing nurse signatures for the ordered Tramadol on multiple dates (05/02, 05/03, 05/09, and 05/10), despite the Treatment Record reflecting that wound care was performed daily on the day shift. On additional dates (05/04–05/06 and 05/11), the MAR entries for Tramadol were signed with code “4” indicating “out of parameters” by a registered nurse, but there were no associated progress notes explaining these entries. The wound care nurse reported that the resident had an order for Tramadol prior to wound care, that she performs wound care Monday through Friday, and that the floor nurse performs it on weekends, and she stated she checks the MAR to ensure the medication was given. The DON stated that nurses are to follow physician orders and document if a resident refuses medication. The facility’s pressure ulcer/skin breakdown protocol required pain assessment and documentation, but the medical record lacked adequate documentation to show that the ordered pain medication was administered or appropriately addressed on the identified dates.
Plan Of Correction
The facility continues to ensure that resident's medical records are complete and accurately documented. IMMEDIATE CORRECTIVE ACTION Resident #62 was assessed by Director of Nursing upon notification of surveyor and resident #62 did not have any adverse outcome related to the alleged deficient practice on 5/13/26. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED All active residents in the facility can potentially be affected by the alleged deficient practice. Director of Nursing and/or designee conducted a comprehensive chart audit to ensure that residents with pain medications were accurately documented on EMAR on 5/15/26. No residents were adversely affected by the alleged deficient practice. SYSTEMATIC CHANGES The Director of Nursing and/or designee initiated ongoing in-service education with clinical staff on standards of accurate medication administration documentation with emphasis on accurate documentation of Pain Medication Refusal. MONITORING Nursing Supervisor and/or designee will conduct random observation and/or audits to ensure accurate documentation of pain medication administration and refusal, 5 days a week for 1 month, then weekly for 3 months. The Director of Nursing and/or designee will report findings of observation/audits to the quality assurance committee monthly for 4 months to ensure continued substantial compliance is achieved and maintained.
Ineffective QAPI Program Fails to Correct Repeated Medication Storage Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to demonstrate an effective Quality Assurance and Performance Improvement (QAPI/QAA) program to correct repeated deficiencies related to medication storage (F0761). Surveyors identified that the facility had previously been cited for failing to properly store medications during a recertification and re-licensure survey with an exit date of October 31, 2024. Despite this prior citation, the same deficient practice of improper medication storage was again identified, indicating that the facility did not effectively correct or prevent recurrence of the problem area. Record review showed that the facility held monthly QAA Committee meetings, as evidenced by sign-in sheets dated 02/10/2026, 03/10/2026, and 04/14/2026. Attendees included the Administrator, DON, Medical Director, and other department heads. The facility’s written QAPI policy, implemented on 9/1/2022 and revised on 1/1/2026, stated that it was the facility’s policy to maintain an effective, comprehensive, data-driven QAPI program focusing on outcomes of care and quality of life, and that the QA Committee was to develop and implement appropriate plans of action to correct identified quality deficiencies. During an interview, the Administrator reported that the QAA Committee membership included the Medical Director, nursing home administrator, other department heads, and invited direct care staff, and that they met monthly and as needed to assess ways to make improvements. However, the survey findings indicated that, despite these meetings and the written QAPI policy, the facility’s QAPI/QAA activities did not result in an effective plan of action to correct the repeated deficiency in medication storage. At the time of the survey, there were 94 residents residing in the facility, and the Administrator was informed of concerns related to the repeated deficiencies and the facility’s QAPI activities.
Plan Of Correction
The facility continues to ensure that the quality assurance and improvement program is used to identify and track areas for improvement throughout the facility. IMMEDIATE CORRECTIVE ACTION Ad hoc QA meeting performed on 5/15/26 to address QAPI/QAA concerns and plan of action for current alleged deficiencies including alleged noncompliance with QAPI/QAA Improvement Activities. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED All active residents in the facility can potentially be affected by the alleged deficient practice. Administrator/Risk Manager reviewed and audited previous 6 months of QA meetings on 5/18/26 to ensure areas of concern were addressed. SYSTEMATIC CHANGES On 5/19/26, ongoing in-services was conducted by Regional Consultant with facility Quality Assurance Committee about Quality Assurance and Performance improvement Policy with emphasis on implementation, monitoring, and evaluation of performance improvement projects. The Quality Assessment and Assurance Committee will meet monthly and conduct random audit of 1 current performance improvement project monthly to validate reported substantial compliance. MONITORING The Interdisciplinary Team as well as Regional Consultant will attend monthly QAPI meeting to ensure QAA Committee compliance with QAPI process. Regional Consultant will assist with random audit process for 3 months. Any and all findings will be reported during monthly quality assurance meeting until substantial compliance is achieved.
Nonfunctioning Call Light and Inaccessible Bell for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in the resident call system when a cognitively impaired resident with aphasia and significant self-care deficits did not have a functioning bedside call light on three separate observations. On each observation, the call light was present near the resident’s bed but was not operational, and the resident’s bell was placed on top of a mini refrigerator beside the bed rather than within reach. The resident’s care plan documented self-care deficits and the need for assistance with most ADLs, including fall and safety precautions, and the MDS showed total dependence for toileting and lower body dressing, setup assistance for eating, partial assistance for upper body dressing, and substantial assistance for showering and position changes. Interviews revealed that the Maintenance Director was unaware that the resident’s call light was not operating, despite a facility program in which department heads are assigned to check resident equipment. The Administrator stated that bedside bells were considered a resident preference and that residents could choose to use either the bell or the call light, but not because the call light was nonfunctional. A CNA reported that staff are expected to ensure call lights are within reach and to report nonfunctioning call lights immediately for repair. The facility’s policy required each resident room to have fully functional bedside, toilet, and shower call devices within reach of residents, with systems tested upon installation, monthly, and after maintenance, and accessible from beds, chairs, and bathroom floors, which was not met for this resident.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration and documentation of medications for several residents. Specifically, for Resident #51, there was an order for Alprazolam that was discontinued, yet doses were documented as removed from the medication cart after the discontinuation date. However, there was no documentation of the medication being administered on the Medication Administration Record (MAR). This indicates a failure in the facility's process for handling discontinued medications and ensuring accurate record-keeping. For Resident #43, there was an order for Clonazepam, but the Medication Monitoring/Control Record showed missing documentation for several doses. The MAR indicated that some doses were administered, but one dose was left blank, suggesting inconsistencies in documentation practices. This inconsistency raises concerns about the accuracy of medication administration records and the potential for medication errors. Resident #83 and Resident #35 also experienced issues with the documentation of controlled medications. For Resident #83, multiple instances were noted where Oxycodone/Apap was removed from the medication cart without corresponding documentation on the MAR. Similarly, for Resident #35, several doses of Oxycodone/Apap were removed from the cart, but there was no documentation of administration on the MAR. These findings highlight a systemic issue within the facility regarding the handling and documentation of controlled substances, which could lead to significant medication management problems.
Medication Security Deficiencies
Penalty
Summary
The facility failed to properly secure medications for a resident and left a medication cart unlocked and unattended. Specifically, medications were left at the bedside of a resident who was cognitively intact and did not have a history of refusing medications or the ability to self-administer them. The medications were placed on the over-bed table by a nurse, and the resident confirmed that the nurse had left them there. The Assistant Director of Nursing acknowledged that the medications were left by the nurse and not brought in by the resident's family. Additionally, a medication cart was observed to be left unlocked and unattended in a hallway with multiple residents, visitors, and staff passing by. A Licensed Practical Nurse admitted to leaving the cart unlocked and unattended but was unsure how it happened. These actions are in violation of the facility's policies on administering and storing medications, which require that medications be administered safely and that medication carts not be left unlocked and unattended.
Failure to Adhere to Fluid Restriction Orders for Dialysis Resident
Penalty
Summary
The facility failed to adhere to fluid restriction orders for a resident undergoing dialysis, identified as Resident #16. The resident was readmitted with diagnoses including End Stage Renal Disease, Muscle Weakness, and Type 2 Diabetes, and was cognitively intact with a Brief Interview of Mental Status score of 15. Physician orders specified a no added salt diet with a 1,500 ml fluid restriction, allocating specific amounts for each meal. However, observations revealed that the resident was provided with excessive fluids, including 16 ounces of water in a Styrofoam cup near her bed and additional fluids during lunch, totaling 828 ml, which exceeded the prescribed 240 ml for the lunch meal. The resident was aware of being on fluid restrictions but was unclear about the specific limits. Interviews with staff highlighted a lack of communication and awareness regarding the resident's fluid restrictions. A Certified Nursing Assistant was unaware that Resident #16 was on fluid restrictions and did not acknowledge providing the excess water. The Clinical Dietitian confirmed that fluid restrictions are listed in the electronic system and on meal tickets, yet the oversight occurred. The Registered Dietitian's progress note indicated the resident's non-compliance with the renal diet and fluid restrictions, and the care plan acknowledged the risk of complications due to hemodialysis, yet the facility failed to ensure compliance with the fluid restriction orders.
Failure to Implement Enhanced Barrier Precautions for Resident with Central Line
Penalty
Summary
The facility failed to properly implement Enhanced Barrier Precautions (EBP) for a resident with a central line, leading to deficiencies in infection prevention and control. The resident, who was admitted with chronic osteomyelitis and type 2 diabetes, was receiving intravenous (IV) therapy with Vancomycin. Despite the facility's policy requiring EBP for residents with indwelling medical devices, no signage was posted outside the resident's room to indicate the need for EBP, and staff did not consistently wear appropriate personal protective equipment (PPE) during care. During observations, surveyors noted that the IV catheter tubing was not maintained in a sterile manner, as it was wrapped around the IV pole without a sterile cap. A Licensed Practical Nurse (LPN) was observed entering the resident's room to flush the central line and attach the IV medication tubing without donning a gown, which is required under EBP. The LPN also failed to clean the tip of the catheter properly before attaching the uncapped IV tubing, further compromising infection control. Interviews with staff, including Certified Nursing Assistants (CNAs) and the Assistant Director of Nursing (ADON), revealed a lack of adherence to EBP protocols. The ADON, who is responsible for posting precautionary signage, acknowledged the absence of a sign for the resident with a central line. The Director of Nursing (DON) also confirmed that the nurse should have worn a gown while providing IV care. These lapses in protocol highlight the facility's failure to maintain adequate infection prevention measures for residents with high-risk medical conditions.
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Nursing homes near North Miami
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Maria Nursing Center | 0.7 mi | ★★★★★ | 4 | 2 |
| North Dade Nursing And Rehabilitation Center | 0.7 mi | ★★★★★ | 9 | 0 |
| Pines Nursing Home | 0.7 mi | ★★★★★ | 0 | 0 |
| The Lilac At Silver Palms | 1.3 mi | ★★★★★ | 13 | 0 |
| Fountain Manor Health & Rehabilitation Center | 1.6 mi | ★★★★★ | 1 | 0 |
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