Biscayne Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility did not maintain an environment free of accident hazards on one (second floor) of two floors. As evidenced by shaving razors observed in Resident #29's room. Staff disposed of lancets in the regular trash and left a housekeeping cart with germicidal wipes unattended and easily accessible. There were 94 residents residing in the facility at the time of the survey. The findings included. 1) An observation on 05/11/2026 at 10:47 AM revealed a shaving razor on the sink in resident #29's. Staff E, Licensed Practical Nurse (LPN) was made aware and entered the room and removed the razor from the sink. At that time, Resident # 29 entered the room and Staff E, LPN asked the resident if the razor belonged to him and Resident # 29 stated: That is not my razor. I keep my razors in the nightstand. At that time, the resident showed the surveyor and Staff E, LPN the shaving razors he kept in the nightstand (Photographic evidence). Staff E, LPN then exited the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility did not adhere to proper medication storage protocols on the second floor, as evidenced by medicated ointments observed in the rooms of Resident #58, Resident #20, and Resident #29. The findings include:1) Observation on 05/11/2026 at 9:07 AM revealed a container of Diclofenac ointment on top of the sink in Resident # 58's room (Photographic evidence).Review of Resident #58's clinical records revealed the resident was admitted on [DATE] with diagnosis that included: Heart Failure and had no cognitive impairment.2) Observation on 05/11/2026 at 9:39 AM and on 05/12/2026 at 11:06 AM a tube of Hydrophilic wound dressing was noted in a basket on Resident # 20's nightstand. (Photo evidence).Review of Resident # 20's clinical records revealed the resident was admitted on [DATE] with diagnosis that included: Cerebral infarction due to embolism of right middle cerebral artery and was severely cognitively impaired.3) Observation on 05/11/2026 at 10:54 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, records reviewed and interviews the facility failed to document adequate information in the medical records for one (Resident # 62) out of two sampled residents with a pressure ulcer. Staff did not sign the Medication Administration Record for pain medication ordered before wound care on several dates in May 2026 for Resident # 62, even though wound care was provided on those days. Five residents with pressure ulcers lived in the facility at the time of the survey. The findings included. During observation on 05/13/2026 at 10:02 AM of Resident # 62's wound care being performed by the facility's Wound Care Nurse and Resident # 62 denied pain at that time.Record review of Resident # 62's clinical record revealed the resident was admitted to the facility on [DATE] with diagnosis that included but not limited to Peripheral Vascular Disease. Review of Resident # 62's care plans that started on 04/13/2026 and revised on 05/05/2026 for a pressure ulcer with interventions that included: Administer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate an effective plan of action to correct repeated deficiencies in the problem area as evidenced by repeated deficient practices for F0761; failed to properly store medications. There were 94 residents residing in the facility at the time of survey. The findings included:Record reviews of the facility's survey history revealed the facility was cited F 0761 during the recertification and Re-licensure survey with an exit date of October 31, 2024. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 02/10/2026, 03/10/2026 and 04/14/2026 revealed the facility had a QAA Committee meeting monthly and attendees included: Administrator, Director of Nursing (DON), Medical Director, and other department heads. Record review of the facility's Policy and Procedure titled, Quality Assurance and Performance Improvement Date Implemented: 9/1/2022 Date Reviewed/ Revised: 1/1/2026 revealed:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to provide pharmaceutical services to ensure the accurate administration and documenting of medications for 4 of 5 sampled residents reviewed for controlled medications (Resident #43, Resident # 51, Resident # 83 and Resident #35) and failed to ensure a discontinued controlled medication was removed from the med cart for 1 of 5 residents reviewed for controlled medications (Resident #51). The findings included: Review of the facility's policy titled, Administering Medications with a reviewed date of January 2024 included in part the following: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 22. As required or indicated for a medication, the individual administering the medication records in the resident's medial record: a. The date and time the medication was administered b. The dosage c. The route of administration Review of the facility's policy titled, Storage of Medications with a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to properly secure dispensed medications left at the bedside for 1 of 1 resident (Resident #39). The facility also failed to ensure that 1 of 4 medications carts was locked and inaccessible to unauthorized staff and residents. The findings included: Review of the facility's policy titled, Administering Medications, dated January 2024, included the following: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 21. The individual administering the medication initials the resident's Medical Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones. Review of the facility's policy titled, Storage of Medications, dated January 2024, included the following: Policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow fluid restriction orders for 1 of 1 resident on dialysis (Resident #16). The findings included: A chart review revealed that Resident #16 was readmitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Muscle Weakness, and Type 2 Diabetes. The Medicare 5-day Minimum Data Set, dated [DATE] showed that Resident #16 had a Brief Interview of Mental Status score of 15, which was cognitively intact. A review of the physician ' s orders showed the following: No added salt diet with 1,500 milliliters (ml) fluid restriction with 1080 ml allocated for dietary. Dietary 240 ml every Dinner meal, dietary 240 ml every Lunch, and 600 ml every Breakfast meal, which was dated 10/22/24. In an observation conducted on 10/28/24 at 11:00 AM, Resident #16 was noted in her room with 16 ounces of water in a Styrofoam cup near her bed on the side table. In an observation conducted on 10/28/24 at 12:20 PM, Resident #16 was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to properly post signage for Enhanced Barrier Precautions (EBP) for a resident with a central line, failed to wear appropriate Personal Protection Equipment (PPE) during care of a central line, and failed to maintain the IV catheter tubing in a manner to prevent infection for 1 of 1 resident reviewed for central line receiving IV therapy (Resident #90). The findings included: Review of the facility's policy titled, Enhanced Barrier Precautions, dated 04/01/24, included the following: Policy: It is the policy of this facility that Enhanced Barrier Precautions (EBP), . will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO. Procedures: EBP consists of the use of gowns and gloves for high-contact care activities…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety that include; ensure the department is free of pest, ensure that hot and cold foods are held at regulatory temperatures, ensure that equipment is cleaned and maintained on a regular basis, and ensure that dietary staff facial hair is properly covered as per regulation. The findings included: 1) During the initial kitchen/food service observation tour conducted on 07/24/23 at 9:00 AM and accompanied with the facility's Food Service (FSD), the following were noted: (a) Flying insects were noted to be observed in the food preparation/tray line serving area, the food storage room, and the main dining room. Flying insects were noted to be landing directly on clean food preparation surfaces, and containers of prepared foods. Dietary staff were observed to be swatting at the flying insects. Four flying insects were observed in the food preparation/serving area. The FSD stated, that there has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for the first and second floor resident rooms, dialysis treatment room, and nursing storage closets and affected one out of 28 sampled residents (Resident #141). The findings included: Review of the facility's policy's and procedures noted the following: Policy and Procedure on Environmental Services dated 09/01/2021 revealed: INTENT: It is the policy of the facility to provide Environmental Services accordance to State and Federal regulations. PROCEDURE: 1. The facility will maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner. 2. The facility will provide a safe, clean, comfortable, and homelike environment, which allows the resident to use his or or her personal belongings to the extent possible. 3. The facility will provide: a. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that foods were not prepared by methods that conserve nutritive value, flavor, and appearance for 4 (#53, #56, #64, and #391) out of 19 residents with physician ordered Pureed diets. The findings included: 1) During the initial kitchen/food service observational tour on 7/24/2023 at 9:00AM, a 1/3 pan of pureed vegetables dated 07/23/23 was located in the walk-in refrigerator. During the initial tour the breakfast/lunch cook, (Staff A) was interviewed and it was reported, the pan was puréed green beans that had been fully cooked and pureed on 07/23/23 and were intended to be served for the lunch meal of 07/24/23. Observation of the green beans revealed them to be thoroughly cooked, pureed and lacked a bright green color. Staff A further stated, all pureed vegetables are regularly cooked and pureed over 24 hours ahead of the intended meal. The surveyor discussed with Staff and the Food Service Director (FSD) that the vegetables were fully cooked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F812 Food Procurement, Store/Prepare/Serve-Sanitary. This practice has the potential to increase the risk of negative resident outcomes and to affect all 91 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with the exit date 08/14/2022 Food Procurement, Store/Prepare/Serve-Sanitary was cited related to the facility failed to ensure foods were prepared and distributed at safe temperatures, as evidenced by a failure to provide food holding temperatures were consistently monitored and recorded for all menu items. During an interview on 07/27/2023 at 01:34 PM, the Nursing Home Administrator and Director of Nursing (DON) revealed, the Quality Assessment and Assurance Committee (QAA) meets the second Thursday of every month. The administrator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to follow infection control standards of practice as evidenced by dialysate (a fluid used during dialysis) jugs on the counter next to a disinfectant spray and sink; personal bags found in storage rooms; a broom/dustpan found in dialysate storage rooms; a biohazard bag on floor; and an overflowing trash bin. These actions have the potential to affect the seven residents who are receiving dialysis including sampled Resident #17. The findings included: On 07/26/23 at 10:17 AM. During an observation of the dialysis treatment room. By the sink area, there were five dialysate jugs and one spray bottle that was labeled disinfection spray, and napkins in a clear bin on the counter. (See photographic evidence) An open trash bin was empty and by the sink. One step-on closable red biohazard bin is at the back of the room. Personal bags were located on the floor shelf of the television stand. (See photographic evidence) In the front storage room, there was a resident scale mechanical lift, there was a chair with rusted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.