East Ridge Rehabilitation And Nursing Center

Based on observations, record review and interviews, the facility failed to provide safe and secure

residents residing in the facility at the time of the survey.

The findings include.Resident #20During the initial observational tour of the facility on 02/23/2026 at 8:46 AM Resident #20 was in bed awake, there was one ointment on the bedside table and one cream on top of the dresser.On 02/24/2026 at 8:00 AM Resident #20 was in bed asleep, an ointment remained on bedside table (Photographic evidence) Resident # 83On 02/23/2026 at 8:59 AM Resident #83 was observed in bed awake, bed in the lowest position, a bottle of eyedrops on the overbed table (Photographic evidence available)On 02/24/2026 at 8:04 AM three (3) tubes of biologicals observed on the bedside table (Photographic evidence available)On 02/25/2026 at 8:17 AM Resident #83 was in bed asleep, wheelchair next to the bed, a bottle of eyedrops on the overbed table.

Interview on 02/25/2026 8:21 AM Registered Nurse (Staff C) assigned to the 2300 and 2400 unit stated: During my rounds if medications are found in the residents' rooms-if the resident is alert and oriented, I ask the resident about the medication and educate the resident about all medications needing to be stored on the nursing cart, any narcotics found are reported to the nursing supervisor for further investigation.

Interview on 02/25/2026 at 8:24 AM Certified Nursing Assistant (Staff B) stated: If I find any medications in the residents' rooms, I notify the nurse of my findings.

Interview on 02/25/2026 at 9:13 AM Certified Nursing Assistant (Staff A) stated: During rounds or at any time on my shift, if I find medications in the residents' room, I notify the nurse and follow up to make sure the medications are removed from the room.

Review of the facility policy and procedure titled Medication Labeling and Storage revision date 02/2023 states: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls.

Only authorized personnel have access to keys.Policy Interpretation and ImplementationMedication Storage4.

Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.5.

Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

105508 02/26/2026

East Ridge Rehabilitation and Nursing Center 19225 SW 87th Ave Cutler Bay, FL 33157

Review of the facility's survey history revealed that during a recertification survey with an exit date of 02/19/2025, the facility was cited under F-F761 - Label/Store Drugs and Biologicals after failing to ensure appropriate storage of medications on the medication cart for one of three medication carts observed.

Observation revealed loose pills in different compartments of the medication drawer and the narcotics lock box was left unlocked in one of two medication rooms.

During the current survey with an exit date of 02/26/2026, repeated deficient practice was identified under F-F761 Label/Store Drugs and Biologicals.

Related medications and biologicals at two residents' bedsides.

Interview on 02/26/2026 at 2:03 PM, the Director of Nursing (DON) revealed the facility has a Quality Assessment and Assurance (QAA) Committee that meets at least quarterly; however, meetings are held monthly on the first Thursday of each month, with the last meeting conducted on 02/19/2026.

The QAA committee includes the required members such as the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Admissions, Social Services, MDS, Activities, Dietary, Wound Care, Restorative Nurse, Infection Preventionist, Therapy, Central Supply, Housekeeping, Maintenance, Committee Physician, Pharmacy, and other department representatives.

The purpose of the QAA committee is to identify potential risks and benefits, determine when a process or intervention is not working effectively.

Issues within departments are identified through routine communication and meetings; when concerns arise, meetings are called as needed, and periodic QAPI meetings review quality measures to support ongoing performance improvement.

The Administrator, DON, and Medical Director meet frequently to address quality concerns, and a daily morning clinical meeting is held to discuss residents' clinical The DON stated the QAA committee determines issues to focus on based on safety risks, infection control concerns, and staff education needs identified during routine monitoring.

Review of policy and procedure titled QAPI Program Systematic Analysis and Systemic Action issued on 11/28/2019, revised on 10/23/2025 revealed that the facility will take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

105508 02/26/2026

East Ridge Rehabilitation and Nursing Center 19225 SW 87th Ave Cutler Bay, FL 33157

Observation on 02/24/2026 at 8:00 AM revealed Resident #20 in bed awake there was an uncapped Urinal on the bedside table.On 02/25/2026 at 8:10 AM Resident #20 was in bed with eyes closed and an uncapped Urinal was observed on the bedside table. On 02/23/2026 at 8:59 AM Resident #83 was in bed awake, an uncapped Urinal was on the bedside table.On 02/24/2026 at 8:04 AM Resident #83 was in bed asleep, there was an uncapped Urinal on the bedside table partially filled with a yellow-colored liquid.On 02/25/2026 at 8:17 AM Resident #83 was in bed asleep, there was an uncapped Urinal on the bedside table partially filled with a yellow-colored liquid.

Interview on 02/25/2026 at 8:21 AM Registered Nurse (Staff C) assigned to the 2300 and 2400 units stated: Oxygen equipment to include mask, tubing, and Spirometers when not in use are stored in clear plastic bags.

The oxygen equipment is changed every Friday night and placed in clear plastic bags labeled with the date.

Urinals are stored in a clear plastic bag covered in the bathroom. At bedtime the urinals are stored on the bedrails with a cover on top for use.

Soiled briefs are disposed of in a closed plastic bag in the soiled utility room bin.

This is to prevent cross contamination between residents and risk of infection for staff and residents.' Interview on 02/25/2026 at 8:24 AM Certified Nursing Assistant (Staff B) revealed oxygen equipment when not in use is stored in a clear plastic bag in the resident's drawer; urinals are stored in the bathroom in clear plastic bags when not in use, dirty adult briefs are placed in the soiled utility room for pick up by housekeeping to prevent infection control issues.

Interview on 02/25/2026 at 9:13 AM Certified Nursing Assistant (Staff A) stated urinals are stored in a clear plastic bag in the bathroom.

Soiled diapers are disposed of in a closed plastic bag in the soiled utility room bin.

Oxygen equipment when not in use is stored in a clear plastic bag in the resident's drawer.

This is done to avoid contamination or infection issues.

Review of the facility policy and procedure titled Infection Control Prevention and Control Program dated 02/21/23 states: The facility shall establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.