Coral Harbor Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Coral Harbor Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF684May 7, 2026

  Complaint #2790808Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) ensure a Registered Nurse (RN) immediately assessed a resident who had fallen and complained of pain. On [DATE], Resident #3 had an unwitnessed fall. The Licensed Practical Nurse (LPN #1) responded to the fall and did not call an RN to assess the resident. The resident complained of pain and was transferred back to bed by two Certified Nursing Assistants (CNAs). On [DATE], 4 days later, the resident was transferred to the emergency room (ER) for an unrelated medical concern and was diagnosed with a right hip fracture. […]

• No harm, potential for more than minimal, widespreadF881May 7, 2026

  Based on an interview and review of other pertinent facility documentation, it was determined that the facility failed to fully implement the antibiotic stewardship program, including ongoing monitoring and use of surveillance criteria when antibiotics were prescribed.This deficient practice was identified for 5 of 5 months of antibiotic stewardship records reviewed and was evidenced by the following:On 5/5/2026 at 11:19 AM, the surveyor interviewed the Infection Preventionist (IP) regarding the facility's Antibiotic Stewardship Program (efforts to ensure that antibiotics were used only when necessary and appropriate). […]

• No harm, potential for more than minimal, patternF695May 7, 2026

  Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide the provision of respiratory care in accordance with professional standards of practice specifically by: a.) not having a physician's order for oxygen administration. b.) not storing an oxygen mask and nasal cannula (NC, a tube used to deliver supplemental oxygen directly into a patient's nostrils) in a protective bag and c.) not ensuring that oxygen equipment, and the humidification bottle was dated.The deficient practice was identified for 2 of 3 residents (Residents #7, and Resident #8) reviewed for Respiratory Care and was evidenced by the following:1.) On 5/3/2026 at 11:02 AM, during the initial tour of the facility, the surveyor observed… […]

• No harm, potential for more than minimal, patternF698May 7, 2026

  Based on observation, interview, and review of the medical record and other facility documentation, it was determined that the facility failed to adjust a resident's medication administration schedule to accommodate dialysis treatments. This deficient practice was identified for 1 of 2 residents (Resident #6) reviewed for dialysis services. This deficient practice was evidenced by the following:On 5/3/2026 at 10:07 AM, the surveyor observed the resident awake in bed. A tray containing covered dishes was in front of him/her. The resident appeared weak. […]

• No harm, potential for more than minimal, patternF755May 7, 2026

  Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards and ensure a medication was administered per the physician's order (PO) within the required timeframe. This deficient practice was identified for 1 of 1 resident (Resident #15) reviewed for insulin and was evidenced by the following:On 5/5/2026 at 11:10 AM, the surveyor observed Resident #15 in the room in bed. The resident was fully dressed and well groomed. The surveyor asked the resident if they received their medication daily and they responded Yes. When the surveyor asked if the medications were administered timely, the resident told surveyor they do not remember. […]