Inspection Reports for South Dade Nursing And Rehab Center
17475 S Dixie Hwy, Miami, FL 33157, FL, 33157
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
74% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
166 residents
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Census: 166
Deficiencies: 3
Dec 11, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication management, and facility environment at South Dade Nursing and Rehabilitation Center.
Findings
The facility was found deficient in obtaining physician orders for a medicated patch for a newly admitted resident, maintaining a safe environment to prevent accidents, and proper labeling and storage of drugs and biologicals, including expired supplies and medications found at residents' bedsides and loose pills in medication carts.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to obtain admission orders for a medicated patch for one newly admitted resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide an environment free of accident hazards; resident found unattended in bed with bed in high position. | Level of Harm - Minimal harm or potential for actual harm |
| Stored drugs and biologicals contrary to professional standards including expired medical supplies, loose pills in medication carts, and medications found at residents' bedsides. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents present: 166
Medication rooms inspected: 3
Medication carts inspected: 6
Expired medical supplies: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse (RN) | Notified about medicated patch and medication storage concerns |
| Staff E | Certified Nursing Assistant (CNA) | Notified about bed safety concern and interviewed regarding fall prevention protocol |
| Staff B | Licensed Practical Nurse (LPN) | Inspected medication cart and reported loose pills |
| Staff D | Certified Nursing Assistant (CNA) | Interviewed about medication storage at bedside |
| Staff F | Registered Nurse (RN) | Interviewed regarding resident medication storage and education |
| Director of Nursing | Director of Nursing | Provided statements regarding new orders for medicated patch and medication storage policies |
| Director of Social Services | Director of Social Services | Stated all medications must be stored and managed by nursing staff |
Inspection Report
Routine
Census: 179
Deficiencies: 9
Jul 26, 2024
Visit Reason
The inspection was a routine survey to assess compliance with federal regulations related to resident rights, PASRR screening, care planning, accident prevention, respiratory care, pharmaceutical services, medication error rates, medication storage, infection control, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were treated with dignity during feeding, incomplete PASRR screening, failure to follow care plans for side rail use, unsafe environment related to smoking materials and unattended side rails, improper oxygen administration, medication errors and omissions, improper medication storage, ineffective quality assurance processes, and failure to maintain infection control standards related to IV dressing changes.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Staff fed residents while standing, failing to honor residents' right to a dignified existence and self-determination. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate Level 1 PASRR screening prior to admission and failed to revise screening following admission for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow care plan for side rail use for two residents, with side rails not used as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a safe environment by allowing a resident to keep smoking materials and unattended side rails in down position. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer oxygen therapy at the prescribed rate for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accuracy in medication administration resulting in three medication omissions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly store medications and biologics, with medications found at residents' bedside and unattended on medication cart. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement effective quality assurance and performance improvement activities to correct repeated deficiencies. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to meet infection control standards for IV dressing changes, with an unchanged dressing observed beyond ordered frequency. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents: 179
Medication administration opportunities: 25
Medication omissions: 3
Oxygen flow rate ordered: 2
Oxygen flow rate observed: 3
BIMS score: 15
BIMS score: 3
IV dressing change frequency: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Observed feeding Resident #117 while standing |
| Staff B | Registered Nurse (RN) | Observed feeding Resident #142 while standing |
| Director of Nursing | Reported staff training on feeding protocol and QAPI committee interview | |
| Staff J | Registered Nurse (RN) | Noted side rails discrepancy for Resident #102 |
| Staff M | Certified Nursing Assistant (CNA) | Placed side rail down for Resident #72 during lunch |
| Staff C | Registered Nurse (RN) | Acknowledged oxygen flow rate error for Resident #26 |
| Staff H | Licensed Practical Nurse (LPN) | Medication administration observation with medication omission for Resident #121 |
| Staff N | Registered Nurse (RN) | Medication administration observation with medication omission for Resident #95 |
| Staff I | Registered Nurse (RN) | Medication administration observation with medication omission for Resident #163 |
| Staff D | Licensed Practical Nurse (LPN) | Removed improperly stored medications from residents' rooms and medication cart |
| Director of Nursing/Quality Assurance | Interviewed regarding QAPI activities | |
| Administrator | Interviewed regarding QAPI activities | |
| Assistant Director of Nursing/Quality Assurance | Interviewed regarding QAPI activities |
Inspection Report
Routine
Census: 179
Deficiencies: 2
Jul 21, 2024
Visit Reason
The inspection was conducted to ensure the nursing home environment is free from accident hazards and provides adequate supervision to prevent accidents, focusing on resident safety related to smoking materials and side rail usage.
Findings
The facility failed to provide a safe environment for two residents: Resident #43 was found with smoking materials while not in the designated smoking area, and Resident #72 was observed with one full-length padded side rail in the down position while unattended. Both incidents indicate lapses in supervision and adherence to facility policies.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident #43 was found with smoking materials while not in the designated smoking area, contrary to facility policy. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #72 was observed in bed with one full-length padded side rail in the down position while unattended by staff. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents who smoked: 26
Residents sampled: 17
Residents affected: 2
BIMS score: 15
BIMS score: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Reported residents are not allowed to keep lighters on their person and that residents have been educated on the protocol | |
| Staff E | Staff stationed in the smoking area who stated smoking materials are kept locked and residents are not allowed to keep cigarettes or lighters on their person | |
| Staff F | Staff stationed in the smoking area who stated smoking materials are kept locked and residents are not allowed to keep cigarettes or lighters on their person | |
| Staff M | Certified Nursing Assistant (CNA) | Placed right-side rail in the down position for Resident #72 to eat lunch and left resident unattended |
| Restorative Registered Nurse (RN) | Stated bilateral full length padded side rails should be in the up position while resident is in bed unless staff is present | |
| Restorative CNA | Conducts rounds to ensure ordered restorative interventions are in place for residents |
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 4
Mar 6, 2023
Visit Reason
The inspection was conducted due to allegations of abuse and neglect involving residents being placed in recliners in the dining room with restraints and inadequate supervision.
Findings
The facility was found to have placed multiple residents in recliners in the dining room with footrests propped up by chairs, restricting movement and constituting restraints. One resident was wedged between a wall and a column. Staff were observed sleeping while residents were unattended. The facility failed to provide adequate supervision, incontinent care, and timely abuse reporting. Immediate Jeopardy was cited and later removed after corrective actions.
Complaint Details
The complaint investigation was triggered by observations on 03/06/2023 at 4:00 AM of seven residents sleeping in recliners with footrests propped up by chairs in the dining room, one resident wedged between a wall and column, and one resident in a wheelchair unattended while a CNA was sleeping. The facility failed to timely report the abuse within two hours as required.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 3
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Residents were placed in recliners with footrests propped up by chairs, restricting movement and constituting restraints. | Level of Harm - Immediate jeopardy to resident health or safety |
| Staff failed to provide adequate supervision; a CNA was observed sleeping while residents were unattended. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to timely report suspected abuse within required two-hour timeframe. | Level of Harm - Minimal harm or potential for actual harm |
| Facility administration failed to ensure effective and efficient use of resources to prevent neglect and ensure residents are free from restraints. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents observed in dining room: 8
Residents on 3rd floor: 58
Residents on 2nd floor: 60
CNAs on 3rd floor: 3
CNAs on 2nd floor: 4
Nurses on 3rd floor: 2
Nurses on 2nd floor: 3
Staff educated: 180
Total staff: 202
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Registered Nurse (Night Supervisor) | Interviewed about residents placed in dining room recliners and supervision. |
| Staff K | Certified Nursing Assistant (CNA) | Observed sleeping while residents unattended; responsible for supervising residents in dining room. |
| Staff C | Registered Nurse | Interviewed about interventions and supervision during night shift. |
| Staff H | Registered Nurse | Interviewed about restraint and abuse concerns related to residents in dining room recliners. |
| Nursing Home Administrator | Administrator | Informed about residents in recliners and restraint concerns; responsible for facility administration. |
| Director of Nursing | Director of Nursing | Informed about residents in recliners and restraint concerns; responsible for nursing services. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Mar 6, 2023
Visit Reason
The inspection was conducted due to complaints and observations related to resident grievances, abuse, neglect, and failure to provide adequate care and supervision.
Findings
The facility failed to implement its grievance protocol for Resident #125, failed to prevent residents from being restrained in recliners in the dining room, failed to provide adequate supervision, and failed to timely report allegations of abuse. Multiple residents were found restrained or neglected, and staff were inadequately trained or supervised. The facility also had medication administration errors and equipment malfunction issues.
Complaint Details
The complaint investigation was triggered by observations of residents restrained in recliners in the dining room, inadequate supervision, and failure to assist a resident with communication. The facility failed to file immediate reports within the required two-hour timeframe for abuse allegations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Level of Harm - Immediate jeopardy to resident health or safety: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to implement grievance protocol and assist Resident #125 with communication. | Level of Harm - Minimal harm or potential for actual harm |
| Residents were restrained in recliners with footrests propped up by chairs, and one resident was wedged between a wall and column restricting movement. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to timely report suspected abuse and neglect within required timeframes. | Level of Harm - Minimal harm or potential for actual harm |
| Medication cart narcotic count discrepancy and failure to follow pharmaceutical procedures. | Level of Harm - Minimal harm or potential for actual harm |
| Dishwashing machine not maintaining required wash and rinse temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Facility administration failed to ensure adequate supervision and care to prevent neglect and restraint use. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents observed restrained: 7
Residents affected by abuse report delay: 8
Staff educated: 180
Narcotic count discrepancy: 1
Dishwasher wash temperature: 130
Dishwasher rinse temperature: 165
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Registered Nurse, Night Supervisor | Named in restraint and supervision deficiencies, admitted to inadequate rounds and supervision. |
| Staff K | Certified Nursing Assistant | Observed sleeping while assigned to supervise residents; involved in restraint use and medication incident. |
| Staff M | Social Services Assistant | Involved in grievance handling and communication assistance for Resident #125. |
| Staff L | Registered Nurse | Interviewed regarding grievance procedures and Resident #125's communication needs. |
| Staff C | Registered Nurse | Reported on restraint use and neglect in dining room; described staff responsibilities. |
| Staff H | Registered Nurse | Interviewed about restraint use and abuse reporting. |
| Staff A | Licensed Practical Nurse | Involved in narcotic count discrepancy and medication administration. |
| Staff B | Registered Nurse Supervisor | Supervised narcotic count investigation and provided education. |
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