Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 South Dade Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Missing Admission Order for Medicated Patch: A resident admitted from the hospital with HTN was observed with an undated medicated patch on the left shoulder, which the resident said was for HTN and changed monthly. Staff were unaware of the patch, and no corresponding physician order was found in the chart, although oral antihypertensive medication orders were present.
Unattended resident observed in high bed position. A resident with intracranial injury, moderate cognitive impairment, and substantial/maximal transfer assistance needs was observed lying in bed with legs over the edge while the bed was in a high position and no staff were present. The resident’s care plan identified fall risk and directed that the bed be kept in the lowest position, and the CNA stated the bed had been left up while waiting for another staff member to help get the resident out of bed.
Surveyors found expired supplies in a medication room, loose pills in two med carts, and medications left at the bedsides of two residents. Staff stated medications should not be kept at the bedside, and the DON confirmed expired items and loose pills should not be present in medication storage areas.
The facility failed to ensure accurate medication administration for three residents, resulting in medication omissions. An LPN dispensed a chewable Calcium tablet instead of the regular form, an RN used a chewable Aspirin instead of the enteric-coated form, and another RN dispensed a Diphenhydramine tablet instead of a capsule. These errors were identified during a survey, highlighting non-compliance with the facility's medication preparation policy.
The facility's QAPI committee failed to effectively address repeated deficiencies in F755 Pharmacy Services and F867 QAPI-QAA Improvement Activities, affecting 179 residents. Despite monthly meetings and a policy for a data-driven QAPI program, the committee's interventions were unsuccessful in resolving these issues.
Two residents were not treated with respect and dignity during dining, as staff members were observed standing while feeding them. A CNA and an RN were seen feeding residents in bed without sitting at their level, contrary to the facility's training and policy on resident rights. The residents had diagnoses including nervous system degeneration and dysphagia.
A facility failed to accurately complete and update a Level 1 PASRR for a resident with documented mental health conditions, including Schizophrenia and Major Depressive Disorder. The PASRR did not reflect the resident's diagnoses, and the facility did not notify the state mental health authority of significant changes in the resident's condition, as required by policy.
The facility failed to adhere to care plans for two residents regarding side rail use. One resident was observed with full-length side rails up, contrary to the care plan specifying half rails. Another resident, with severe cognitive impairment, was left unattended with one side rail down, against the care plan for seizure precautions. Staff actions did not align with the facility's policy requiring adherence to care plans.
A resident with COPD was observed receiving oxygen at 3 LPM instead of the prescribed 2 LPM on multiple occasions. Staff interviews revealed a lack of awareness of the correct order, and the facility's policy requires adherence to physician orders for oxygen administration.
The facility exceeded a 5% medication error rate due to three incidents where staff administered incorrect forms of medication. An LPN on the second floor dispensed a chewable Calcium tablet instead of the regular form, while an RN on the third floor gave a chewable Aspirin instead of the enteric-coated form. Another RN on the third floor administered a Diphenhydramine tablet instead of the capsule form. Staff acknowledged the errors and noted the absence of correct forms in their carts.
The facility failed to properly store medications and biologicals for two residents, with items found in their rooms against protocol. Additionally, an LPN left pills unattended on a medication cart. The DON stated that daily sweeps are conducted to remove unauthorized items, and the facility's policy requires proper labeling and storage of all medications.
A resident in the facility was found with an unchanged IV dressing, dated four days prior, despite physician's orders for changes every 72 hours. The resident, admitted with endocarditis, had specific orders for dressing changes and IV site checks, which were not followed. The facility's infection preventionist confirmed that physician's orders should supersede the facility's weekly dressing change protocol.
The facility failed to enforce its smoking policy and ensure proper use of side rails, leading to unsafe conditions for two residents. A resident was found with smoking materials outside the designated area, contrary to facility policy. Another resident, with epilepsy, was left unattended with one side rail down, against their care plan. These lapses indicate deficiencies in supervision and policy adherence.
Missing Admission Order for Medicated Patch
Penalty
Summary
The facility failed to obtain admission orders for a medicated patch for Resident #175, who was admitted from the hospital six days earlier with diagnoses including essential hypertension. On observation, the resident had an undated patch on the left shoulder and stated that it was for hypertension and was to be changed monthly. The resident also stated that the patch had come from the hospital and that staff had been told about it, but no action had been taken. Staff C, RN, stated that she did not know about the patch and would check. The 3rd floor RN Supervisor later stated that no one knew what type of patch it was, that the resident did not want to remove it, and that the doctor had been spoken to and would come to see the resident and possibly give new orders. The supervisor also stated that skin checks are done upon admission, but that this was missed. Record review showed physician orders for oral metoprolol succinate for hypertension, but there was no corresponding physician's order for the patch at the time of the observation.
Unattended resident observed in high bed position
Penalty
Summary
The facility failed to provide an environment free of accident hazards for one resident when Resident #156 was observed lying in bed unattended with the bed in a high position. On 12/09/25 at 10:20 AM, the surveyor observed the resident with legs extended over the edge of the bed while no staff were present. A call light was within reach, but the resident’s arms appeared contracted. The surveyor immediately notified a CNA, who then lowered the bed. During interview, the CNA stated that if no staff are present, the bed should be low and the head of bed up so the resident does not fall, and explained that the bed had been left up while another staff member was being sought to help take the resident out of bed. Record review showed the resident was admitted with intracranial injury with loss of consciousness, had a BIMS score of 11 indicating moderate cognitive impairment, required substantial/maximal assistance for transfers, and had a care plan identifying fall risk with an intervention to keep the bed in the lowest position. Facility staff and the DON/ADON were informed of the concern, and the facility policy stated residents will receive adequate supervision, assistance, and assistive devices to aid in the prevention of falls.
Improper Storage of Medications and Supplies
Penalty
Summary
Drugs and biologicals were stored contrary to professional standards when surveyors found expired medical supplies, loose pills in medication carts, and medications left at residents’ bedsides. In the 4th Floor Medication Room, expired supplies were identified, including Eternal Distal End Transition Connectors with cap, an IV start kit, and suction yankers. In addition, a loose pill was found in the 4th Floor East Medication Cart and another loose pill was found in the 2nd Floor East Medication Cart, with staff acknowledging that loose pills should not be inside the carts. Medications were also observed at the bedsides of two residents. One resident was seen with medicated shampoo at the bedside and later with two packets of Vitamin C on the nightstand; staff removed the items after being notified. Another resident had over-the-counter cough medication observed on the bed and bedside table tray on multiple observations, and the resident stated the medication belonged to her. Staff interviews indicated that medications should not be kept at the bedside and that nursing staff were responsible for storing and managing medications, while the DON stated expired items should not be present in medication rooms and loose pills should not be in carts.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure the accuracy of medication administration for three residents, resulting in medication omissions. During an observation, a Licensed Practical Nurse (LPN) was found to have dispensed a chewable Calcium 500 plus vitamin D tablet instead of the regular tablet as per the physician's order for a resident. The LPN acknowledged the error and stated that the correct form was not available in the medication cart. In another instance, a Registered Nurse (RN) dispensed a chewable Aspirin 81 mg tablet instead of the enteric-coated form as ordered for a resident's Deep Vein Thrombosis Prophylaxis. The RN recognized the mistake and corrected it by disposing of the incorrect form. Additionally, another RN dispensed a Diphenhydramine Hydrochloride 25 mg tablet instead of the capsule form as prescribed for a resident's skin erythema. The RN admitted the error and planned to notify the physician. The facility's policy on medication preparation and dispensing was not adhered to, leading to these deficiencies.
Repeated Deficiencies in Pharmacy Services and QAPI Activities
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to effectively implement corrective actions for identified quality deficiencies, specifically related to F755 Pharmacy Services and Procedures and F867 QAPI-QAA Improvement Activities. These deficiencies were noted during a recertification survey, with the exit date of March 9, 2023, and have the potential to affect all 179 residents residing in the facility at the time of the survey. The facility's policy, implemented in June 2021, mandates a comprehensive, data-driven QAPI program, but the committee did not demonstrate effective action plans to address the repeated deficiencies. The QAPI committee, which includes the Administrator, Medical Director, Director of Nursing, and other interdisciplinary team members, meets monthly to review departmental reports, incidents, and trends. Despite these meetings, the facility was cited for repeated deficiencies, indicating a failure in the QAPI process to address and correct the issues effectively. The committee's process involves root cause analysis and intervention development, but the repeated citations suggest these measures were not successful in resolving the deficiencies.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to ensure that two residents were treated with respect and dignity during dining, as staff members were observed standing while feeding them. Resident #117 was seen sitting up in bed while a Certified Nursing Assistant (CNA), identified as Staff A, set up the meal tray and fed the resident while standing. Staff A explained that she did not initially get a chair because it was behind a wheelchair but intended to grab it afterward. Resident #117's clinical records indicate diagnoses including Degenerative Disease of the Nervous System, Unspecified Psychotic Disturbance, Mood Disturbance, and Anxiety. Similarly, Resident #142 was observed in bed while a Registered Nurse (RN), identified as Staff B, fed the resident while standing. Staff B expressed comfort with feeding the resident in this manner and questioned whether a chair was necessary. Resident #142's clinical records show diagnoses of Dysphagia Following Other Cerebrovascular Disease and Generalized Muscle Weakness. The Director of Nursing reported that CNAs and nurses receive orientation training on feeding protocols, which include sitting at the same level as residents to maintain dignity. The facility's policy on resident rights emphasizes the right to a dignified existence and communication.
Inaccurate PASRR Documentation for Resident with Mental Health Conditions
Penalty
Summary
The facility failed to ensure a Level 1 Preadmission Screening and Resident Review (PASRR) was completed accurately prior to admission and did not revise the screening following admission for a resident. The resident had a documented history of mental health conditions, including Schizophrenia and Major Depressive Disorder, which were not accurately reflected in the PASRR documentation. The initial PASRR indicated no suspicion of Serious Mental Illness (SMI) or Intellectual Disability (ID), despite the resident's medical records and psychological evaluations indicating otherwise. The Director of Nurses (DON) stated that the PASRR process was based on information provided by the hospital before admission and did not require updating after a new psychiatric evaluation. The facility's policy required notification to the state mental health authority after a significant change in a resident's mental condition, which was not adhered to in this case. The resident's care plan acknowledged the risk of drug-related side effects due to psychotropic medications for their mental health diagnoses, yet the PASRR documentation did not align with these diagnoses.
Failure to Follow Care Plans for Side Rail Use
Penalty
Summary
The facility failed to follow the care plan for two residents, leading to deficiencies in their care. Resident #102 was observed with full-length bilateral side rails in the up position, contrary to the physician's order and care plan, which specified the use of half side rails as an enabler. Despite the resident expressing comfort and safety with the full-length rails, the care plan required monitoring for placement and safety, and the use of half side rails to be evaluated quarterly. The discrepancy was noted by a registered nurse who acknowledged the need to adjust the side rails to comply with the physician's order. Resident #72 was observed with one full-length padded side rail in the down position while the other was up, which was inconsistent with the care plan that required bilateral full padded side rails for seizure precautions. The resident, who has severe cognitive impairment, was left unattended with one side rail down during lunch. A certified nursing assistant admitted to lowering the rail to accommodate a side table for the resident to eat independently, while the restorative RN confirmed that both rails should be up unless staff is present. The facility's policy mandates that all staff be knowledgeable of and have access to the resident's care plan, which was not adhered to in these instances.
Failure to Administer Oxygen Therapy at Prescribed Rate
Penalty
Summary
The facility failed to administer oxygen therapy at the prescribed rate for a resident, identified as Resident #26, who was observed receiving oxygen via nasal cannula at 3 Liters Per Minute (LPM) instead of the prescribed 2 LPM. This discrepancy was noted during multiple observations over several days. The resident, who has a medical history including Chronic Obstructive Pulmonary Disease (COPD) and dependence on supplemental oxygen, was observed in bed with the oxygen concentrator set incorrectly on two occasions, while it was set correctly on a third observation. Interviews with staff revealed a lack of awareness regarding the correct oxygen order for the resident. A Registered Nurse admitted to not realizing the order was for 2 LPM, and the Director of Nursing confirmed that the protocol required nurses to check oxygen settings at the start of each shift. The facility's policy mandates that oxygen should be administered according to physician orders, except in emergencies, highlighting a failure in adherence to this policy.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication omissions out of 25 medication administration opportunities. During the survey, three separate incidents were observed where staff administered incorrect forms of medication to residents. On the second floor, a Licensed Practical Nurse (LPN) dispensed a chewable Calcium 500 plus vitamin D tablet instead of the regular tablet as per the physician's order for a resident. The LPN acknowledged the error and stated that the correct form was not available in the cart. On the third floor, a Registered Nurse (RN) was observed administering a chewable Aspirin 81 mg tablet instead of the enteric-coated form as ordered by the physician for another resident. The RN recognized the mistake and disposed of the incorrect pill. In a separate incident on the same floor, another RN dispensed a Diphenhydramine Hydrochloride 25 mg tablet instead of the capsule form as prescribed for a resident. The RN admitted to not having the correct form in the cart and planned to notify the physician. The facility's policy on medication preparation and dispensing was reviewed, which requires confirmation of the correct medication name and dose, but these procedures were not followed in the observed cases.
Improper Storage of Medications and Biologicals
Penalty
Summary
The facility failed to properly store medications and biologicals for two residents, as observed during a survey. For Resident #62, a tube of Hydrocortisone 1/2% cream and a bottle of normal saline solution were found on the resident's nightstand. The surveyor notified the supervising RN and an LPN, who confirmed that over-the-counter medications should not be kept in residents' rooms for safety reasons. Similarly, for Resident #373, a metered dose inhaler and a tube of pain relief cream were found on the side table next to the resident's bed. These items were also removed by the LPN upon notification by the surveyor. Additionally, on the second floor, three pills were found unattended in a medication cup on top of the East Medication cart. The LPN responsible for the cart admitted to leaving the medication unattended to retrieve a book, acknowledging that this was not proper protocol. The Director of Nursing later stated that department heads conduct daily sweeps of residents' rooms to remove unauthorized medications or materials, and educate residents if such items are found. The facility's policy mandates that all medications and biologicals be labeled and stored according to federal and state regulations.
Infection Control Deficiency Due to Unchanged IV Dressing
Penalty
Summary
The facility failed to meet infection control standards for a resident due to an unchanged intravenous (IV) dressing. The deficiency was observed when a resident was found with an IV site dressing dated four days prior, despite physician's orders requiring dressing changes every 72 hours. Additionally, an empty IV medication bag was observed hanging next to the resident, indicating a lapse in proper IV management. The resident, who was admitted with a diagnosis of endocarditis, had specific orders for transparent dressing changes and IV site checks every shift, which were not adhered to. The facility's infection preventionist confirmed that the facility protocol for midline or central IV line dressing changes is weekly, but acknowledged that the physician's order should take precedence. The facility's policy on dressing changes, implemented in March 2020, also specifies that physician's orders will dictate the type and frequency of dressing changes. Despite these protocols, the IV dressing for the resident was not changed as required, leading to the deficiency noted by the surveyors.
Deficiencies in Smoking Policy Enforcement and Side Rail Use
Penalty
Summary
The facility failed to provide a safe environment for two residents, leading to deficiencies in supervision and accident prevention. Resident #43 was observed with smoking materials, including a lighter and cigarettes, while not in the designated smoking area. Despite the facility's policy that prohibits residents from keeping smoking materials on their person, Resident #43 was able to access and retain these items. The staff in the smoking area confirmed that smoking materials should be stored in a locked caddy and only provided to residents in the designated area. However, Resident #43 was able to bypass this protocol, indicating a lapse in the facility's enforcement of its smoking policy. Additionally, Resident #72 was found with one of two full-length padded side rails in the down position while in bed and unattended by staff. This was contrary to the care plan, which required both side rails to be up as a precaution due to the resident's epilepsy. The resident was observed in this state on multiple occasions, suggesting a failure in staff adherence to the care plan. The staff member responsible for lowering the side rail did so to accommodate a side table for the resident to eat independently, but left the resident unattended, which was against the facility's policy for seizure precautions. The facility's policies on smoking and accident prevention were not adequately enforced, leading to these deficiencies. The smoking policy clearly states that residents should not have smoking materials on their person, and the accident prevention policy requires that the resident environment be free from hazards with adequate supervision. The failure to adhere to these policies resulted in unsafe conditions for the residents involved.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coral Reef Subacute Care Center Llc | 0.9 mi | ★★★★★ | 1 | 0 |
| East Ridge Rehabilitation And Nursing Center | 2.1 mi | ★★★★★ | 5 | 0 |
| Jackson Memorial Perdue Medical Center | 2.4 mi | ★★★★★ | 5 | 0 |
| St Annes Nursing Center, St Annes Residence Inc | 3 mi | ★★★★★ | 4 | 0 |
| Harmony Health Center | 4.9 mi | ★★★★★ | 0 | 0 |
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