Coral Reef Subacute Care Center LLC

In the surveyor’s words

From the most serious findings on record at Coral Reef Subacute Care Center LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 6, 2024

  Based on observations record reviews and interviews, the facility's staff failed to supervise and implement adequate measures to prevent the elopement for one (Resident #1) out of three residents sampled. The facility's system failure, lack of adequate supervision and a failure in ensuring an adequate alert monitoring system were in place enabled Resident #1 who had risk factors that include visual impairment and seizure disorder, exited the facility undetected on 09/01/2024 shortly after lunchtime. Resident #1 who had displayed and voiced his intent to leave the day prior ambulated 3.2 miles from the facility in areas that has high traffic volume, intersections and cross streets; these factors increased the likelihood of an adverse outcomes, serious injury and serious harm or death. […]

• Immediate jeopardy, isolatedF600Oct 22, 2021

  Based on interviews, observations and records reviewed, the facility failed to provide care, services, and supervision to prevent suicide for one resident (Resident #1) out of 10 residents sampled. The facility failed to effectively monitor behaviors related to Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . While unsupervised in his room, Resident #1 suffocated himself by placing a trash bag over his head, resulting in death by suicide. On [DATE], it was determined the findings of the survey posed immediate jeopardy to the health and safety of all residents admitted to the facility. […]

• Immediate jeopardy, isolatedF656Oct 22, 2021

  Based on interviews, policy and records reviewed, the facility failed to implement, develop an effective care plan for the quality of care and treatments required by one (Resident #1) out of 10 sampled residents reviewed during this complaint investigation. The facility failed to develop a care plan to address Resident #1's pain and did not develop a care plan that addressed the Resident's use of [CONDITION(S)] medications [MEDICATION(S)] and [MEDICATION(S)]. The facility also failed to implement the Resident's care plan for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result of these deficient practices, Resident #1 suffocated himself by placing a plastic trash bag over his head, resulting in his death by suicide. […]

• Immediate jeopardy, isolatedF742Oct 22, 2021

  Based on records reviewed and interviews, the facility failed to ensure adequate behavior monitoring and supervision was provided for one resident (Resident #1) out of 10 sampled residents of the 17 Residents that received Anti anxiety medications and 47 residents that received antidepressant medications. The facility failed to effectively monitor behaviors related to Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 while unsupervised in his room, placed a plastic trash bag over his head and suffocated himself resulting in death by suicide. The Findings Included: Record review of the Federal 1 day report revealed, on [DATE] at 9:00 PM, Resident #1 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Nov 17, 2022

  Based on observation and interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner and in accordance with professional standards The findings included: During the initial kitchen tour, on 11/14/22 at 8:19 AM, accompanied by the Registered Dietitian, the Administrator and the Dietary Director, the following were noted: -There was an accumulation of food debris on the floor in the dry storage area. -There was residue on the wall of the dry storage area indicative of something being splashed. -The walk in cooler floor had numerous broken tiles. -There was an accumulation of debris on the floor of the walk in cooler. -There was an accumulation of residue on the vents of the exhaust fans over the cooking equipment. […]