Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Coral Reef Subacute Care Center Llc during CMS and state inspections, most recent first.
Staff did not answer multiple incoming calls to the nursing stations after hours, despite the presence of nurses and available phones. This failure to respond to calls had the potential to impact all residents' rights to communication and dignity.
Surveyors found that 11 resident rooms had furniture in disrepair, including chipped paint, ingrained dirt, and black marks on chests of drawers, as well as littered floors and a broken bathroom dispenser. Staff interviews confirmed awareness of these issues, and the facility's policy requires a clean, comfortable, and homelike environment, which was not met.
A CNA was observed standing while feeding a resident, contrary to facility policy requiring staff to sit next to residents during meals to promote dignity. The CNA stated a preference for standing, and the issue was acknowledged by the staff educator as a concern regarding proper feeding practices and resident dignity.
A resident receiving IV antibiotics was found with an IV infusion pump on one side of the bed and the electrical cord stretched across the bed under the resident to reach an outlet, creating a potential accident hazard. The resident, who had multiple chronic conditions and moderate cognitive impairment, was exposed to this unsafe setup due to the lack of accessible electrical outlets and improper cord management by staff.
Surveyors found that medications and ointments, including Zinc Oxide and a Sodium Chloride syringe, were left unsecured on dressers in several resident rooms, contrary to facility policy requiring all drugs and biologicals to be stored in locked compartments. The East Unit Manager confirmed these items should have been properly secured.
The facility's QAPI/QAA committee did not implement effective action plans to address repeated deficiencies in MDS coding accuracy and secure medication storage. Despite regular committee meetings and broad staff involvement, the same issues persisted, affecting the care of 156 residents.
A resident with visual impairment and seizure disorder eloped from the facility undetected, walking 3.2 miles through high-traffic areas. The facility staff were unaware of the resident's absence until contacted by the resident's sister. The facility failed to implement its policy on wandering and elopements, and the incident was not documented or reported to administration.
The facility failed to secure medication carts and properly handle controlled substances, with multiple instances of unlocked carts, inaccurate narcotic counts, and improper medication disposal. Staff were observed tossing medications in the trash and storing discontinued medications improperly. The facility's policy requires immediate documentation and proper disposal, but these protocols were not followed.
The facility's staff failed to follow infection control policies, as observed with soiled linen and garbage left on the floor in hallways and doorways. CNAs were seen improperly handling soiled items and not following procedures to maintain a sanitary environment, despite being aware of the correct protocols.
Failure to Answer Incoming Calls After Hours
Penalty
Summary
Facility staff failed to answer incoming phone calls after 8:00 PM, as evidenced by six documented unanswered calls made by surveyors between 9:34 PM and 10:28 PM. Observations showed that each nursing station was equipped with multiple desk phones and a portable phone, and three nurses were present at each station during the observational tour. According to the Administrator, after 8:00 PM, calls are routed directly to the nursing stations, where nurses are responsible for answering them. However, during the times in question, no staff responded to the incoming calls. Interviews with staff confirmed that calls for residents are typically transferred to a portable phone and brought to the resident. The facility's policy states that employees must treat residents with kindness, respect, and dignity, and that residents have the right to communicate with people and services both inside and outside the facility. The failure to answer calls after 8:00 PM had the potential to affect all 159 residents in the facility at the time of the survey.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a sanitary, clean, and homelike environment for residents in 11 out of 32 rooms on the East Unit. Specific findings included chest of drawers in multiple rooms with chipped paint, ingrained dirt, and black marks, as well as a floor littered with paper in one room and a broken toilet tissue dispenser in another. These conditions were directly observed during the initial tour and resident screenings, and photographic evidence was collected. Interviews with facility staff revealed that while there is a system in place for reporting maintenance concerns, it was unclear if the issues with the chest of drawers had been previously reported or addressed. The Director of Maintenance acknowledged awareness of the furniture's disrepair, noting that previous attempts to paint the laminate furniture were unsuccessful and that replacement was planned as part of ongoing renovations. The facility's policy requires a safe, clean, and homelike environment, but the observed conditions did not meet these standards at the time of the survey.
Failure to Provide Dignified Dining Experience During Resident Feeding
Penalty
Summary
A Certified Nursing Assistant (CNA) was observed standing while feeding a resident during a meal. When questioned, the CNA stated that he preferred to stand and believed it allowed him to take his time and ensure the resident's safety. This action was witnessed by a surveyor and acknowledged by the facility's Staff Educator as a concern related to dignity during dining and proper feeding practices. Review of the facility's policies revealed that residents are to be treated with dignity and respect, including being provided with a dignified dining experience. The facility's dining room audit policy specifically instructs staff to sit next to residents while assisting them to eat, rather than standing over them. The observed practice did not align with these established policies and procedures.
Unsafe IV Pump Cord Placement Creates Accident Hazard
Penalty
Summary
A deficiency was identified when a resident was observed with an intravenous (IV) infusion pump positioned on the right side of their bed, while the IV site was on the resident's left arm. The electrical cord for the IV pump was extended across the bed, running under the resident, and plugged into an outlet on the left side of the bed. This setup created a potential accident hazard, as the cord was not safely managed and was positioned in a way that could cause harm to the resident. The assigned registered nurse acknowledged the unsafe positioning of the electrical cord and indicated that there were no electrical outlets available on the right side of the bed, which contributed to the improper setup. The resident involved had a history of chronic medical conditions, including a breakdown of a cardiac electronic device, chronic obstructive pulmonary disease, and emphysema. The resident was receiving IV antibiotics for influenza-like symptoms and was noted to be moderately cognitively impaired. The care plan indicated ongoing IV therapy through a mid-line in the left arm. The facility's policy required prompt investigation and reporting of accidents or incidents, but the unsafe environment was observed during the survey, indicating a failure to maintain a hazard-free area and provide adequate supervision to prevent accidents.
Unsecured Medications and Ointments Found in Resident Rooms
Penalty
Summary
Surveyors observed that medications and treatment ointments were not stored in accordance with facility policy and professional standards. During an initial facility tour and resident screenings, Zinc Oxide ointment was found unsecured on dressers in two resident rooms, and a half-full 0.9% Sodium Chloride syringe was found on top of a dresser in another resident's room. These items were not stored in locked compartments as required by both facility policy and federal regulations. Photographic evidence was obtained to document these findings. An interview with the East Unit Manager, a Registered Nurse, confirmed that ointments and creams should be kept in residents' personal drawers and that Sodium Chloride solutions must be stored on the medication cart or in the medication room. Review of the facility's medication labeling and storage policy further emphasized that all medications and biologicals must be stored in locked compartments, with access limited to authorized personnel. At the time of the survey, 156 residents resided in the facility.
Repeated Deficiencies in MDS Accuracy and Medication Storage Due to Ineffective QAPI Oversight
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) committee failed to implement effective action plans to correct previously identified quality deficiencies. Specifically, the facility was cited for repeated deficiencies in the areas of F641 (Accuracy of assessment) and F761 (Label/Store drugs and biologicals). The facility did not accurately code the Minimum Data Set (MDS), particularly in section B regarding corrective lenses, and failed to ensure medications were securely stored. These issues were identified during a recertification survey and had been cited in the facility's survey history. Despite the QAPI committee meeting monthly and including a broad range of facility leadership and staff, the committee did not adequately monitor or address these ongoing problem areas. The committee's continued evaluation of their performance improvement projects did not result in effective corrective actions, as evidenced by the recurrence of the same deficiencies. At the time of the survey, there were 156 residents residing in the facility.
Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to supervise and implement adequate measures to prevent the elopement of a resident who had risk factors including visual impairment and seizure disorder. The resident, who had previously expressed a desire to leave, managed to exit the facility undetected shortly after lunchtime. The resident walked 3.2 miles from the facility through areas with high traffic volume, increasing the likelihood of adverse outcomes. The facility staff were unaware of the resident's absence until the resident's sister was contacted by a convenience store owner. The facility's policy on wandering and elopements was not effectively implemented. The policy required that residents at risk for wandering or elopement have care plans with strategies to maintain their safety. However, the staff failed to prevent the resident from leaving and did not initiate the missing resident emergency procedure promptly. The resident's absence was not noticed until the sister called the facility, indicating a lack of adequate supervision and monitoring systems. The incident was not documented, and the administration was not informed, as required by the facility's policy. The Registered Nurse assigned to the resident did not report the incident or document it, citing shock as the reason for the oversight. The facility's failure to follow its own policies and procedures contributed to the resident's elopement and the delay in recognizing and responding to the situation.
Medication Handling and Security Deficiencies
Penalty
Summary
The facility's staff failed to ensure the security and proper handling of controlled medications, as evidenced by multiple instances of medication carts being left unlocked and unattended. During an initial tour, a medication cart assigned to a registered nurse was observed unlocked and unattended. Additionally, another cart was found in a similar state, with discrepancies noted in the narcotic disposition logs for several residents. These discrepancies included mismatches between the documented on-hand amounts and the actual counts in the bingo cards, indicating errors in medication administration and documentation. Further observations revealed improper disposal of medications, with a registered nurse seen tossing medications into a trash can attached to a medication cart. When questioned, the nurse retrieved the medications and placed them in a sharps container but was unable to articulate the facility's policy for medication disposal. Additionally, discontinued medications, including insulin and topical ointments, were found improperly stored in drawers at the nurses' station instead of being returned to the pharmacy. The facility's policy on controlled substances requires immediate documentation of medication removal and administration, as well as proper disposal procedures. However, staff interviews and observations indicated a lack of adherence to these protocols. The Director of Nursing was informed of these issues, which included inaccurate narcotic counts, improper medication disposal, and failure to secure medication carts, all of which were acknowledged by the staff involved.
Infection Control Deficiency: Improper Handling of Soiled Linen and Garbage
Penalty
Summary
The facility's staff failed to implement infection prevention and control policies and procedures, as evidenced by improper handling of soiled linen and garbage. Observations revealed that several clear plastic bags containing trash and soiled linen were left on the floor in the facility's hallways and resident doorways. Certified Nursing Assistants (CNAs) were observed placing soiled linen in bins and then handling clean linen without proper precautions. Additionally, CNAs were seen dragging bags containing soiled linen and trash along the floor from one wing to another, and placing soiled items in plastic bags on the floor near clean linen carts. Interviews with staff confirmed that they were aware of the proper procedures for handling soiled linens and garbage, which include placing them in plastic bags and then in designated bins in the biohazard room. The facility's policy on laundry and bedding, published shortly before the observations, states that soiled laundry should be handled, transported, and processed according to best practices for infection prevention and control. Despite this, staff were observed not following these procedures, leading to a failure in maintaining a sanitary environment and increasing the risk of communicable diseases and infections.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Miami
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Dade Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 5 | 0 |
| East Ridge Rehabilitation And Nursing Center | 3 mi | ★★★★★ | 5 | 0 |
| Jackson Memorial Perdue Medical Center | 3.3 mi | ★★★★★ | 5 | 0 |
| St Annes Nursing Center, St Annes Residence Inc | 3.3 mi | ★★★★★ | 4 | 0 |
| Harmony Health Center | 4.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.