Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 East Ridge Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A CNA was observed standing while feeding a resident, despite knowing she was supposed to sit at eye level, and another resident's indwelling urinary catheter drainage bag was visible from the hallway without a privacy cover. Records showed the first resident had a traumatic SAH diagnosis, while the second resident had obstructive and reflux uropathy with an indwelling catheter for urinary retention and moderate cognitive impairment.
Unsecured Medications and Biologicals in Resident Rooms: Two residents had ointments, cream, eyedrops, and other biologicals left on bedside tables and dressers in their rooms instead of being stored in locked compartments. Staff said they notify the nurse when medications are found in resident rooms, and the facility policy states medications and biologicals must be kept in locked storage when not in use.
Repeated F761 deficient practice was cited after surveyors found medications and biologicals at the bedsides of two residents. The facility had previously been cited for improper medication storage, including loose pills in a medication drawer and an unlocked narcotics lock box. The DON stated the QAA/QAPI process includes monthly meetings, routine communication, and monitoring, but the deficiency was again identified on survey.
Improper Storage of Resident Care Items and Soiled Brief: An adult brief was found stored in the hallway, a resident’s spirometer was left uncovered on an overbed table, and two residents had uncapped urinals left on bedside tables, including one partially filled with yellow liquid. Staff gave inconsistent accounts of how oxygen equipment, urinals, and soiled briefs were stored, despite the facility IPC policy requiring a safe, sanitary, and comfortable environment.
The facility failed to secure a narcotics lock box in the medication refrigerator, which contained insulin and Ativan, due to a warped lock. Additionally, a resident received Meloxicam in tablet form despite the EMAR indicating it should be in capsule form. The LPN acknowledged the discrepancy and planned to verify the order with the pharmacy.
The facility failed to properly store medications, as observed with loose pills in a medication cart and an unlocked narcotic lock box in the medication room. The RN attempted to identify and dispose of the loose pills, while the ADON found the lock box's lock to be warped and unreported prior to the observation.
The facility failed to secure a medication lock box and administered medication in the wrong form to a resident. The lock box in the medication refrigerator was found unlocked due to a warped lock, and a resident received a tablet instead of a capsule as per the EMAR. The LPN planned to verify the order with the pharmacy, and the Consultant Pharmacist suggested the error was likely human. These issues indicate non-compliance with the facility's pharmaceutical procedures.
The facility failed to properly store medications, as observed with loose pills in a medication cart and an unlocked lockbox in the medication storage room. The RN stated that carts are cleaned daily, and the ADON noted the lockbox issue was unreported.
The facility did not maintain fire doors according to NFPA 101, as there was no documentation of fire door testing by knowledgeable individuals in the past year. This was discovered during a records review with the Plant Security Manager, who acknowledged the lack of documentation. The absence of required annual inspections and testing of fire door assemblies led to this deficiency.
A resident with a history of falls and high fall risk experienced a delay in care after a fall due to untimely reporting by staff. Despite immediate care being provided, the fall was not reported to the physician until much later, delaying the resident's hospital evaluation and the identification of an acute fracture. The facility's protocols for timely communication were not followed, contributing to the delay in treatment.
Failure to Preserve Resident Dignity During Feeding and Catheter Care
Penalty
Summary
The facility failed to promote dignity and respect for residents during care and while providing privacy for personal medical equipment. On 02/23/2026 at 8:51 AM, a CNA was observed standing next to the bed feeding Resident #48 from the breakfast tray on the overbed table while the resident and CNA were the only people in the room. The CNA stated she knew she was supposed to be sitting and feeding the resident, but the resident's husband was using the chair. Resident #48's record showed admission to the facility with a diagnosis of traumatic subarachnoid hemorrhage without loss of consciousness, subsequent encounter. The facility policy titled Meal Services and Dignified feeding assistance stated that staff assisting with meals must promote dignity by sitting at eye level when assisting residents. On 02/25/2026 at 09:23 AM, Resident #4's indwelling urinary catheter drainage bag was observed visible from the hallway without a privacy cover and anchored to the left side of the bed. Resident #4's record showed a re-entry to the facility with a diagnosis of obstructive and reflux uropathy, and physician orders indicated an indwelling urinary catheter for urinary retention. The resident's MDS identified moderate cognitive impairment, wheelchair use, and the need for partial to moderate assistance with ADLs. Staff interviews confirmed that the drainage bag should be inside a privacy bag and not visible when entering the room.
Unsecured Medications and Biologicals in Resident Rooms
Penalty
Summary
The facility failed to provide safe and secure storage of biologicals for two residents. During the initial observational tour, Resident #20 was observed in bed with an ointment on the bedside table and a cream on top of the dresser. The next day, an ointment was still on the bedside table while the resident was asleep. Resident #83 was observed in bed with a bottle of eyedrops on the overbed table, and later three tubes of biologicals were observed on the bedside table. On a subsequent observation, Resident #83 was asleep with a bottle of eyedrops still on the overbed table. Staff interviews indicated that when medications are found in residents’ rooms, nursing staff are notified and, if the resident is alert and oriented, the resident is questioned and educated about medications needing to be stored on the nursing cart. The facility policy titled Medication Labeling and Storage states that medications and biologicals are to be stored in locked compartments under proper environmental controls, and that compartments containing medications and biologicals are locked when not in use. The observations showed that ointments, cream, eyedrops, and other biologicals were left in resident rooms rather than secured in locked storage.
Repeated Medication Storage Deficiency
Penalty
Summary
Repeated deficient practice for F761 Label/Store Drugs and Biologicals was identified after the facility failed to demonstrate that effective action plans were implemented and sustained to correct prior quality deficiencies. Survey history showed that during a recertification survey with an exit date of 02/19/2025, the facility was cited under F761 after medications were found improperly stored on a medication cart, including loose pills in different compartments of a medication drawer and an unlocked narcotics lock box in one of two medication rooms. During the current survey with an exit date of 02/26/2026, surveyors again identified F761 concerns related to medications and biologicals at the bedsides of two residents. The facility had 69 residents at the time of the survey. The DON stated the facility has a QAA Committee that meets at least quarterly, though meetings were held monthly, with the last meeting on 02/19/2026. The DON also described the committee membership and stated that issues are identified through routine communication, meetings, and monitoring, while the facility policy on QAPI states that actions are taken to improve performance and measure whether improvements are realized and sustained.
Improper Storage of Resident Care Items and Soiled Brief
Penalty
Summary
The facility failed to follow infection prevention and control procedures for the environment and for three residents. During observations, an adult brief was seen stored between the wall and handrail in the 2300 hallway next to a resident room. Resident #17 was observed in bed with eyes closed, and a spirometer on the overbed table was uncovered on 02/24/2026 and remained uncovered on 02/25/2026. Resident #20 was observed in bed with an uncapped urinal on the bedside table on 02/24/2026, and the uncapped urinal remained on the bedside table on 02/25/2026. Resident #83 was observed in bed with an uncapped urinal on the bedside table on 02/23/2026, and on 02/24/2026 and 02/25/2026 the uncapped urinal remained on the bedside table, partially filled with a yellow-colored liquid. Staff interviews revealed differing descriptions of how oxygen equipment, urinals, and soiled briefs were stored, while the facility policy stated the infection prevention and control program was intended to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to adhere to its pharmaceutical procedures as per its policy, as observed during a survey. In one of the two medication storage rooms reviewed, the narcotics lock box in the medication refrigerator was found unlocked. This lock box contained an emergency kit with five vials of insulin and one vial of Ativan. The Assistant Director of Nursing (ADON) attempted to lock the box using several keys but was unsuccessful, as the lock was warped and unable to be secured. The ADON stated that this issue had not been reported prior to the survey observation. Additionally, there was a discrepancy in the administration of medication to a resident. The Electronic Medication Administration Record (EMAR) documented an order for Meloxicam 7.5 mg to be given in capsule form twice a day for pain, while the resident's Bingo Card indicated the medication was being administered in tablet form. The Licensed Practical Nurse (LPN) administering the medication acknowledged the discrepancy and stated they would contact the pharmacy to verify the order. The facility's Consultant Pharmacist noted that the tablet form could be given with physician authorization, suggesting the documentation error was likely human error.
Plan Of Correction
DISCLAIMER STATEMENT: Preparation and/or execution of this plan of correction in general, or this corrective action in, does not constitute an admission or agreement by this facility of the facts alleged or conclusions set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with state and federal laws. This plan of correction constitutes a written allegation of substantial compliance with Federal Medicare and Medicaid requirements. 1. On , the lock box was repaired. On the with a new lock box was replaced lock box. On the physician ARNP was contacted, and order was revised; medication was received matching revised order for Resident #180 on the same day. 2. All residents have the potential to be affected by this deficient practice. Facility conducted an audit of all lock boxes to ensure all lock boxes were working correctly and address, if needed. Facility conducted an audit of all orders to ensure physician order matched the type of medication provided by the pharmacy. 3. The Director of Nursing, or designee(s) will educate all staff on Pharmacy Services, Procedures, Pharmacist, Records CFR(s): 483.45(a)(b)(1)-(3), 59A-4.112(1), FAC Pharmacy Policies and Procedures and facilitys Storage of Medications and Administering Medications policies and procedures. 4. The Nurses will conduct medication cart and lock box check daily. The Director of Nursing and/or designee will conduct a weekly medication cart and medication room quality review. The findings will be reported to the Quality Assurance Process improvement (QAPI) committee monthly and then quarterly once substantial compliance has been achieved.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medications on one of the three medication carts observed. During an observation of medication Cart #3400 with a Registered Nurse (RN), three loose round white pills and several pieces of empty medication packaging were found in the second drawer of the medication cart. The RN stated that she would don gloves, attempt to identify the pills, and dispose of them in the drug buster located in the medication cart. It was also noted that the medication carts are cleaned daily on every shift. Additionally, during an observation of the medication storage room on the facility's second floor with the Assistant Director of Nursing (ADON), the narcotic lock box in the medication refrigerator was found unlocked. The ADON attempted to secure the lock box with several available keys but was unable to do so, as the lock was warped. The lock box contained an emergency kit with five vials of insulin and one vial of Ativan. The ADON stated that the issue had not been reported prior to the observation and that a work order would be needed for repair. The facility's policy on medication storage, revised in April 2007, requires that all drugs and biologicals be stored in a safe, secure, and orderly manner.
Plan Of Correction
DISCLAIMER STATEMENT: Preparation and/or execution of this plan of correction in general, or this corrective action in , does not constitute an admission or agreement by this facility of the facts alleged or conclusions set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with state and federal laws. This plan of correction constitutes a written allegation of substantial compliance with Federal Medicare and Medicaid requirements. 1. On , Staff C immediately discarded the 3 round white pills and empty medication packaging found in the second drawer of Medication Cart #3400. Staff C and ADON immediately deep clean Medication Cart #3400. On the lock box was repaired. On the lock box was lock box, replaced with a new. 2. All residents have the potential to be affected by this deficient practice. Facility conducted an audit of all medication carts to ensure cleanliness of all medication carts. Facility conducted an audit of all lock boxes to ensure all lock boxes were working correctly and address, if needed. 3. The Director of Nursing, or designee(s) will educate all staff on Label, Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2), 59A-4.112(6), FAC Drug Storage and facilitys Storage of Medications and Administering Medications policies and procedures. 4. The Nurses will conduct medication cart and lock box check daily. The Director of Nursing and/or designee will conduct a weekly medication cart and medication room quality review. The findings will be reported to the Quality Assurance Process Improvement (QAPI) committee monthly and then quarterly once substantial compliance has been achieved.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to adhere to its pharmaceutical procedures, as evidenced by two key observations. During an inspection of the medication storage room on the second floor, the lock box within the medication refrigerator was found unlocked. This lock box contained an emergency kit with several vials, and the Assistant Director of Nursing (ADON) was unable to secure it due to a warped lock. The ADON admitted that this issue had not been reported prior to the survey. This oversight indicates a lapse in the facility's policy that requires all compartments containing drugs and biologicals to be locked when not in use. Additionally, there was a discrepancy in the administration of medication to a resident. The Electronic Medication Administration Record (EMAR) indicated that the resident was to receive a 7.5 mg capsule twice a day, but the resident was being given a 7.5 mg tablet instead. The Licensed Practical Nurse (LPN) involved stated they would contact the pharmacy to verify the order. The facility's Consultant Pharmacist noted that the tablet could be administered with physician authorization, suggesting the documentation error was likely human error. This incident highlights a failure to follow the facility's policy of verifying medication orders and ensuring the correct form of medication is administered to residents.
Plan Of Correction
DISCLAIMER STATEMENT: Preparation and/or execution of this plan of correction in general, or this corrective action in does not constitute an admission or agreement by this facility of the facts alleged or conclusions set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with state and federal laws. This plan of correction constitutes a written allegation of substantial compliance with Federal Medicare and Medicaid requirements. 1. On the lock box was repaired. On lock box was replaced lock box. On the 17, 2025, the physician ARNP was contacted, and order was revised: medication was received matching revised order for Resident #180 on the same day. 2. All residents have the potential to be affected by this deficient practice. Facility conducted an audit of all lock boxes to ensure all lock boxes were working correctly and address, if needed. Facility conducted an audit of all orders to ensure physician order matched the type of medication provided by the pharmacy. 3. The Director of Nursing, or designee(s) will educate all staff on Pharmacy Services, Procedures, Pharmacist, Records CFR(s): 483.45(a)(b)(1)-(3), 59A-4.112(1), FAC Pharmacy Policies and Procedures and facilitys Storage of Medications and Administering Medications policies and procedures. 4. The Nurses will conduct medication cart and lock box check daily. The Director of Nursing and/or designee will conduct a weekly medication cart and medication room quality review. The findings will be reported to the Quality Assurance Process Improvement (QAPI) committee monthly and then quarterly once substantial compliance has been achieved.
Medication Storage Deficiency
Penalty
Summary
The facility failed to provide appropriate storage of medications on one of the three medication carts observed. During an observation of medication Cart #3400 with a Registered Nurse (RN), three loose round white pills and several pieces of empty medication packaging were found in the second drawer of the medication cart. The RN revealed that the medication carts are cleaned daily on every shift, indicating a lapse in maintaining the medication cart in a secure and orderly manner. Additionally, during an observation of the medication storage room on the facility's second floor with the Assistant Director of Nursing (ADON), the lock box in the refrigerator was found unlocked. The lockbox contained an emergency kit with five vials of medication. The ADON attempted to secure the lock box with several keys but was unsuccessful, stating that the lock was warped and this issue had not been reported prior to the survey. The facility's policy requires that all drugs and biologicals be stored in a safe, secure, and orderly manner, which was not adhered to in this instance.
Plan Of Correction
DISCLAIMER STATEMENT: Preparation and/or execution of this plan of correction in general, or this corrective action in does not constitute an admission or agreement by this facility of the facts alleged or conclusions set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with state and federal laws. This plan of correction constitutes a written allegation of substantial compliance with Federal Medicare and Medicaid requirements. 1. On , Staff C immediately discarded the 3 round white pills and empty medication packaging found in the second drawer of Medication Cart #3400. Staff C and ADON immediately deep clean Medication Cart #3400. On the lock box was repaired. On the lock box was replaced with a new lock box. 2. All residents have the potential to be affected by this deficient practice. Facility conducted an audit of all medication carts to ensure cleanliness of all medication carts. Facility conducted an audit of all lock boxes to ensure all lock boxes were working correctly and address, if needed. 3. The Director of Nursing, or designee(s) will educate all staff on Label, Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2), 59A-4.112(6), FAC Drug Storage and facility's Storage of Medications and Administering Medications policies and procedures. 4. The Nurses will conduct medication cart and lock box check daily. The Director of Nursing and/or designee will conduct a weekly medication cart and medication room quality review. The findings will be reported to the Quality Assurance Process Improvement (QAPI) committee monthly and then quarterly once substantial compliance has been achieved.
Failure to Maintain Fire Doors as per NFPA 101
Penalty
Summary
The facility failed to maintain fire doors in accordance with NFPA 101, as evidenced by the absence of documentation for the performance of fire doors testing by knowledgeable individuals within the last 12 months. This deficiency was identified during a records review process conducted between 11:30 am and 5:00 pm on February 17, 2025, with the Plant Security Manager. The lack of documentation indicates that the required annual inspection and testing of fire door assemblies, as stipulated by NFPA 80, were not performed or recorded. During a staff interview conducted within the same timeframe, the Plant Security Manager acknowledged the absence of documentation for the fire doors testing. The report highlights that individuals performing door inspections and testing must possess the necessary knowledge, training, or experience to demonstrate their ability, and written records of these inspections and tests must be maintained and available for review. The facility's failure to adhere to these requirements resulted in the noted deficiency.
Plan Of Correction
1. All fire doors were inspected and tested by a certified third-party vendor. 2. All residents have the potential to be affected by this deficient practice. 3. Facilities and IT Manager, Security and Transportation Manager, and Associate Executive Director have been in-serviced by the Administrator regarding annual inspecting and testing of fire doors in accordance with NFPA. 4. The Quality Assurance Process Improvement (QAPI) Committee will monitor annually for compliance. 1. All fire doors were inspected and tested by a certified third-party vendor. 2. All residents have the potential to be affected by this deficient practice. 3. Facilities and IT Manager, Security and Transportation Manager, and Associate Executive Director have been in-serviced by the Administrator regarding annual inspecting and testing of fire doors in accordance with NFPA. 4. The Quality Assurance Process Improvement (QAPI) Committee will monitor annually for compliance.
Delayed Reporting of Fall Leads to Fracture
Penalty
Summary
The facility failed to ensure that a resident received timely care and treatment following a fall, which resulted in a delay in addressing a fracture. The resident, who had a history of falls and was at high risk for further incidents, fell in the early hours of the morning. Despite the fall occurring around 3 AM, the incident was not reported to the physician until approximately 8 PM the same day, leading to a delay in the resident being sent to the hospital for further evaluation. The resident had a complex medical history, including a previous fracture, generalized muscle weakness, and impaired mobility, which contributed to their high fall risk. The resident was found on the floor by staff, and although immediate care was provided, the necessary protocol of notifying the physician was not followed promptly. The delay in reporting the fall and subsequent delay in hospital evaluation meant that the resident's acute fracture involving the right superior and inferior pubic rami was not identified until later, after a CT scan was conducted at the hospital. The facility's policies and procedures were not adhered to, as the nurse responsible for the resident's care did not report the fall in a timely manner, which is a requirement for ensuring residents receive appropriate and timely medical attention. The facility had fall precautions in place, such as floor mats and a low bed position, but the failure to promptly communicate the incident to the physician and other relevant staff members resulted in a significant delay in the resident receiving the necessary medical evaluation and treatment.
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Illustrative
What surveyors actually found near you
We read the 161 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
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Nursing homes near Cutler Bay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jackson Memorial Perdue Medical Center | 0.5 mi | ★★★★★ | 5 | 0 |
| South Dade Nursing And Rehabilitation Center | 2.1 mi | ★★★★★ | 5 | 0 |
| Coral Reef Subacute Care Center Llc | 3 mi | ★★★★★ | 1 | 0 |
| St Annes Nursing Center, St Annes Residence Inc | 3.2 mi | ★★★★★ | 4 | 0 |
| Harmony Health Center | 6.9 mi | ★★★★★ | 0 | 0 |
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