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Health Inspection Summary

Coral Reef Subacute Care Center LLC

9869 SW 152nd Street

Miami, FL 33157

(305) 255-3220

Deficiency Category	Inspection Date: 1/19/24 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 11/17/22 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 11/21/20 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	1	0	4
Quality of Life and Care Deficiencies	2	1	6
Infection Control Deficiencies	1	0	1
Resident Assessment and Care Planning Deficiencies	4	1	3
Nursing and Physician Services Deficiencies	0	1	0
Resident Rights Deficiencies	0	1	3
Nutrition and Dietary Deficiencies	2	1	1
Pharmacy Service Deficiencies	2	2	4
Environmental Deficiencies	1	0	1
Administration Deficiencies	1	2	4

Detailed result for inspection on 1/19/24

Date of last standard health inspection:	1/19/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	12/6/24Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	14
Average number of Health Deficiencies in Florida:	7.2
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.	1/19/24	2/18/24	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	12/6/24	1/19/25	4 - Immediate jeopardy to resident health or safety	Few
Provide safe and appropriate respiratory care for a resident when needed.	1/19/24	2/18/24	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	12/6/24	1/19/25	2 - Minimal harm or potential for actual harm	Some

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
PASARR screening for Mental disorders or Intellectual Disabilities	1/19/24	2/18/24	2 - Minimal harm or potential for actual harm	Few
Ensure each resident receives an accurate assessment.	1/19/24	2/18/24	2 - Minimal harm or potential for actual harm	Few
Assess the resident when there is a significant change in condition	1/19/24	2/18/24	2 - Minimal harm or potential for actual harm	Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	1/19/24	2/18/24	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.	1/19/24	2/18/24	2 - Minimal harm or potential for actual harm	Few
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	1/19/24	2/18/24	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	1/19/24	2/18/24	2 - Minimal harm or potential for actual harm	Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	12/6/24	1/19/25	2 - Minimal harm or potential for actual harm	Some

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Keep all essential equipment working safely.	1/19/24	2/18/24	2 - Minimal harm or potential for actual harm	Some

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	1/19/24	2/18/24	2 - Minimal harm or potential for actual harm	Few

Detailed result for inspection on 11/17/22

Date of last standard health inspection:	11/17/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	No complaint inspections
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	9
Average number of Health Deficiencies in Florida:	6.2
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide safe and appropriate respiratory care for a resident when needed.	11/17/22	1/6/23	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
PASARR screening for Mental disorders or Intellectual Disabilities	11/17/22	1/6/23	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Post nurse staffing information every day.	11/17/22	1/6/23	2 - Minimal harm or potential for actual harm	Few

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Reasonably accommodate the needs and preferences of each resident.	11/17/22	1/6/23	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	11/17/22	1/6/23	2 - Minimal harm or potential for actual harm	Many

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	11/17/22	1/6/23	2 - Minimal harm or potential for actual harm	Few
Ensure medication error rates are not 5 percent or greater.	11/17/22	1/6/23	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	11/17/22	1/6/23	2 - Minimal harm or potential for actual harm	Few
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.	11/17/22	1/6/23	2 - Minimal harm or potential for actual harm	Few

Detailed result for inspection on 11/21/20

Date of last standard health inspection:	11/21/20Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	No complaint inspections
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	No infection control inspections
Total number of Health Deficiencies for this nursing home:	27
Average number of Health Deficiencies in Florida:	5.8
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few
Develop and implement policies and procedures to prevent abuse, neglect, and theft.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few
Respond appropriately to all alleged violations.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few
Provide safe and appropriate respiratory care for a resident when needed.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	11/21/20	12/31/20	4 - Immediate jeopardy to resident health or safety	Some

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure each resident receives an accurate assessment.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few
Ensure services provided by the nursing facility meet professional standards of quality.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few
Reasonably accommodate the needs and preferences of each resident.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Some
Ensure medication error rates are not 5 percent or greater.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Hire a qualified full-time social worker in a facility with more than 120 beds.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Many
Administer the facility in a manner that enables it to use its resources effectively and efficiently.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Few
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Many
Have a plan that describes the process for conducting QAPI and QAA activities.	11/21/20	12/31/20	2 - Minimal harm or potential for actual harm	Many

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	12/6/24	1/19/25	4 - Immediate jeopardy to resident health or safety	Few
Provide and implement an infection prevention and control program.	12/6/24	1/19/25	2 - Minimal harm or potential for actual harm	Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	12/6/24	1/19/25	2 - Minimal harm or potential for actual harm	Some

Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.

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