Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aventura Rehab And Nursing Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, severe cognitive impairment, and a history of falls was observed in a bed left in a high position with the call light out of reach, despite a care plan and physician orders for fall precautions and keeping the bed in the lowest position. The CNA acknowledged forgetting to lower the bed, and the RN, nursing supervisor, and DON confirmed that the bed should be low when staff are not present.
A resident’s Level I PASRR was completed inaccurately when the Social Services Director omitted Anxiety from the MI/suspected MI section, despite the resident being readmitted from the hospital with Anxiety and having an order for PRN lorazepam for Anxiety. The resident also had diagnoses including mood disorder, major depressive disorder with psychotic symptoms, and psychosis, and the director stated she made a mistake.
Failure to verify PEG tube placement before administering meds. An RN gave four meds via a resident’s PEG tube after flushing with water, but did not check placement or residual first. The resident had hemiplegia/hemiparesis after cerebral infarction, moderate cognitive impairment, and a feeding tube. The nursing supervisor stated placement and residual are to be checked before giving meds through an enteral tube, and the RN said it was forgotten.
A resident on the fall management program was observed in a bed left in a high position with the call light out of reach and no staff present; the resident had Alzheimer’s disease, severe cognitive impairment, and was dependent on staff for toileting and hygiene. In a separate observation, a housekeeping cart on the fourth floor was left unattended with a spray bottle easily accessible, and staff stated chemicals are supposed to be kept locked.
Medication administration was not accurate or timely for multiple residents. One resident with a PEG tube did not receive an ordered protein supplement for wound healing during observation, yet the RN signed the EMAR as if it had been given. Another resident received a Lovenox injection ordered SQ, but the nurse administered it at an IM site. A third resident’s scheduled AM meds were given about 2 hours late, despite the facility’s stated 1-hour window for medication timing.
Medication error rate exceeded the allowed threshold when an RN gave scheduled meds late to two residents and administered Lovenox by the wrong route/site for one resident. One resident received several 9:00 AM meds about 1 to 2 hours late, and another resident received multiple 9:00 AM meds late as well. The DON stated meds may be given within 1 hour before or after the scheduled time, and the facility policy required meds to be given safely, timely, and according to prescriber orders.
Unattended Medications During Administration: Staff left medications unattended during med pass in multiple instances, including at a resident’s bedside, on a side table next to another resident, and on top of a med cart while an RN stepped away to store insulin. The DON stated meds must remain in sight and the facility policy requires drugs and biologicals to be stored securely in locked compartments and that unlocked med carts are not left unattended.
QAPI/QAA failed to show an effective plan of action to correct repeated deficiencies after prior citations for F761 and F689. Survey findings again identified improper medication storage and labeling during med administration and failure to prevent accident hazards, with the issues affecting 78 residents. The facility's QAPI plan called for a data-driven program, and monthly QAA meetings were documented with the Administrator, DON, Medical Director, and other dept heads present.
A resident with moderate cognitive impairment and a history of leaving facilities was able to exit undetected after staff failed to recognize her elopement risk and did not implement appropriate supervision or a care plan. Despite prior orders for a wander alert device and information from the transferring facility, the resident left through an open exit and was missing for several hours before being found by law enforcement.
The facility failed to maintain the confidentiality of residents' health care information on two medication carts. On the first-floor South medication cart, a computer screen displaying residents' information was left open and unattended, which was observed by a surveyor. The Director of Nursing and a Registered Nurse were notified, and the screen was closed. On the third floor, an LPN left a computer screen open on a medication cart while assisting a resident, displaying residents' information. The facility's policy requires safeguarding e-PHI from unauthorized access, which was not followed.
The facility failed to maintain a safe and homelike environment, with a broken nightstand in a resident's room and water-stained ceiling tiles on the third floor. Additionally, lint traps in the laundry room were not cleaned as per policy, posing a fire risk. These issues indicate lapses in maintenance and adherence to safety protocols.
A facility failed to ensure an environment free from accident hazards for a resident with seizures, as bilateral side rails were observed in the upward position with foam padding. The resident's care plan and physician's orders included padded side rails for seizure precautions, but the facility's policy requires identifying and addressing potential hazards, which was not adequately done.
A resident was prescribed Seroquel for schizoaffective disorder without supporting documentation for the diagnosis. The resident's records indicated diagnoses of psychosis and anxiety disorder, but the PASRR did not identify a serious mental illness. The facility's policy requires medications to be clinically indicated for a documented condition, which was not adhered to in this case.
The facility failed to properly store medications, with surveyors observing unattended medication carts with unsecured medications and expired tracheostomy kits. Nurses left carts unlocked or with open drawers, contrary to facility protocol requiring medications to be locked when unattended.
Fall Precaution Not Followed for Resident With Severe Cognitive Impairment
Penalty
Summary
The facility did not implement the fall care plan for one resident who was identified as at risk for falls. The resident had diagnoses including Alzheimer’s disease and atherosclerotic heart disease of native coronary artery without angina pectoris, and the clinical record showed the resident was care planned for fall risk related to weakness, history of fall, and medication regimen, with an intervention to keep the bed in the lowest position. The physician’s orders included fall precautions every shift, and the 5-day MDS indicated severe cognitive impairment with a BIMS score of 4 out of 15 and dependence on staff for toileting and hygiene. During observation, the resident was found in a bed positioned high with the call light out of reach. The surveyor remained with the resident, and when the CNA returned to the room, the CNA acknowledged the concern. Interviews with the CNA, nursing supervisor, RN, and DON confirmed that the bed should be left in the lowest position when staff are not present and that the resident’s bed had not been lowered at the time of the observation.
PASRR Form Omitted Anxiety Diagnosis
Penalty
Summary
The facility did not accurately complete the Level I Preadmission Screening and Resident Review (PASRR) form for one of three sampled residents diagnosed with a serious mental illness. Resident #9 was admitted to the facility with diagnoses that included Anxiety, Unspecified Mood Affective Disorder, Major Depressive Disorder recurrent severe with psychotic symptoms, and unspecified Psychosis, but the most recent PASRR completed by the Social Services Director on 03/17/2026 checked Depressive disorder and did not check Anxiety in Section I for MI or suspected MI. Record review showed Resident #9 had an admission date of 11/08/2022 and a readmission date of 03/13/2026 from the hospital with a diagnosis of Anxiety. The resident’s orders included Lorazepam 0.5 mg by mouth as needed for Anxiety. The Social Services Director stated that she completed the PASRR for the resident and, when residents are readmitted from the hospital, she reviews the PASRR if there were discrepancies and would complete a new PASRR; when asked whether Anxiety should have been included because the resident was taking medication for Anxiety upon admission, she stated, "I made a mistake."
Failure to Verify PEG Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for administering medications via PEG tube for one resident with a PEG tube. During an observed medication pass, an RN verified physician orders, prepared four medications, entered the resident’s room, performed hand hygiene, collected water, and donned gloves. The resident was awake in bed with tube feeding off. The RN attached a 60 ml syringe to the PEG valve, administered 30 ml of water, and then gave four medications through the PEG tube, flushing with 30 ml of water between doses, but did not check tube placement or residual before administering the medications. The resident involved had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the non-dominant side and encounter for attention to gastrostomy. The MDS indicated a BIMS score of 7, showing moderate cognitive impairment, and that the resident had a feeding tube. When interviewed, the nursing supervisor stated nurses are to check placement and residual before administering any medications via an enteral tube because it could pose an aspiration danger to the resident. The RN stated the placement and residual were not checked because it was forgotten. The facility policy titled, Administering Medications through an Enteral Tube, stated to verify placement of the feeding tube before administering feeding or medication.
Unsecured hazards and unsafe resident setup observed
Penalty
Summary
The facility failed to provide an environment free of accident hazards for a resident on the fall management program when the resident was observed in a bed positioned at a high level with the call light out of reach and no staff present. The resident had Alzheimer’s disease and atherosclerotic heart disease, was admitted and readmitted to the facility, and was care planned for fall risk related to weakness and a history of falls. The resident’s record included a physician order for fall precautions every shift, and the 5-day MDS documented severe cognitive impairment with dependence on staff for toileting and hygiene. The CNA later stated the bed had not been lowered because she left the room to get help with a transfer, and the nursing supervisor and DON stated the bed should be left in the lowest position when staff are not present. The facility also failed to keep hazardous chemicals secured when a housekeeping cart was observed unattended on the fourth floor with a spray bottle easily accessible. A follow-up observation showed the spray bottle remained accessible while the cart was still unattended. Housekeeping staff stated chemicals are to be kept locked, and the Housekeeping Director stated staff are to keep all chemicals locked in the housekeeping cart for resident safety.
Medication Administration Errors and Late Doses
Penalty
Summary
Pharmaceutical services were not provided to ensure accurate and timely medication administration for two residents. For one resident with hemiplegia and hemiparesis following cerebral infarction and a PEG tube, the medication observation showed multiple ordered medications were administered via PEG, but the ordered House Liquid protein supplement for wound healing was not given during the observation. The resident was awake in bed with tube feeding off, and the RN later stated she had been waiting until the feeding was off before giving it. The EMAR had already been signed for the protein liquid during the observation, even though the RN stated she was supposed to only sign for medications and supplements after they were given. For another resident, the surveyor observed a nurse administering scheduled 9:00 AM medications, including oral medications and a Lovenox injection. The physician order showed Lovenox 40 mg/0.4 ml was ordered subcutaneously once daily at 9:00 AM, but the nurse administered it at an IM site and stated she inserted the needle at a 15% angle. The resident’s record showed diagnoses including aftercare following joint replacement surgery, infection and inflammatory reaction due to an internal left knee prosthesis, essential hypertension, and long-term anticoagulant use. A third resident also received scheduled 9:00 AM medications later than ordered. During observation, the nurse administered multiple oral medications at 11:05 AM, and the nurse stated medications are given within one hour before or after the scheduled time, but in this case the medication was given later because the resident was in therapy and asked the nurse to come back later. The DON stated medications can be given one hour before or after the scheduled time and that if given late, the nurse must notify the doctor. The facility policy stated medications are to be administered in a safe and timely manner and that the individual administering the medication initials the MAR after giving each medication and before administering the next ones.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent, with the survey finding a medication error rate of 24.24 percent. During observations, Staff A, RN administered medications to Resident #46 that were ordered for 9:00 AM at 10:14 AM, including Amlodipine 10 mg PO, Doxycycline 100 mg PO, and Lovenox 40 mg/0.4 ml. The Lovenox was ordered as a subcutaneous injection, but Staff A, RN administered it at an IM site, and the resident showed signs of discomfort during and after the injection. When asked about the injection site, Staff A, RN stated the needle was inserted at a 15% angle. A second observation showed Staff A, RN administering multiple 9:00 AM medications to Resident #73 at 11:05 AM, including Multiple Vitamins, Carvedilol 25 mg, Clopidogrel 75 mg, Fluoxetine 20 mg, and Letrozole 2.5 mg. Staff A, RN stated medications are typically given within one hour before or after the scheduled time and said Resident #46 was late because he was in therapy and Resident #73 asked her to return later. The DON stated medications can be given one hour before or after the scheduled time and that if a medication is given late, the nurse must notify the doctor. The facility policy stated medications are to be administered in a safe and timely manner and in accordance with prescriber orders, with medication administration times determined by resident need and benefit, not staff convenience.
Unattended Medications During Administration
Penalty
Summary
The facility failed to properly store medications during medication administration by leaving drugs unattended in resident care areas and on a medication cart. During observation of medication administration for Resident #72, Staff B, RN left medication at the resident’s bedside while performing hand hygiene. Staff B stated that the pills should not have been left at the bedside because the resident could have grabbed them unsupervised, and the DON stated the bedside table should have remained with the medication and in sight for safety. A separate observation on the 4th floor showed Staff G, RN pouring medications at the medication cart and then walking away to place insulin in the refrigerator, leaving medications on top of the cart. Staff G later stated the medications were left there while she went to store the insulin. In another observation, Staff J, RN left medications on the side table next to Resident #27 while washing hands in the bathroom. Staff J stated another resident could have taken the medications and she would not have known. The facility policy reviewed stated drugs and biologicals are to be stored in a safe, secure, orderly manner in locked compartments, and that unlocked medication carts are not left unattended.
QAPI Failed to Correct Repeated Deficiencies
Penalty
Summary
The facility's QAPI/QAA activities failed to demonstrate an effective plan of action to correct repeated deficiencies in the problem area. Record review showed the facility had previously been cited for F761 and F689 during the recertification and re-licensure survey with an exit date of 09/19/2024, and the current findings again identified repeated deficient practices involving improper storage and labeling of medications during medication administration and failure to prevent accident hazards. These repeated deficient practices were identified as part of the survey findings and were noted to have the potential to affect the 78 residents residing in the facility at the time of survey. Record review of the facility's QAPI plan dated 3/10/2025 showed a policy to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program focused on indicators of care outcomes and quality of life. Review of QAPI committee meeting sign-in sheets dated 03/31/2026 showed monthly QAA committee meetings with attendance by the Administrator, Medical Director, DON, and other department heads. During interview on 04/16/2026, the Administrator/QAA and DON stated the QAPI team included the Medical Doctor, Administrator, DON, department heads, and a direct care staff member, and that QAPI was used to discuss continuous quality improvement and review whether Performance Improvement Plans were working using quantitative data. The surveyor informed the Administrator of the repeated deficiency concerns that would be cited, and the Administrator stated, "We will address all these concerns."
Resident Elopement Due to Inadequate Supervision and Risk Assessment
Penalty
Summary
A deficiency occurred when a newly admitted resident, who was moderately impaired and had diagnoses including major depression and open-angle glaucoma, was able to leave the facility undetected. The resident was observed ambulating toward an exit and subsequently took an elevator to the first floor, where she exited through a door that was open during the day. Staff, including housekeeping and nursing, attempted to intervene but were unable to prevent the resident from leaving. The resident was not located within the facility or surrounding area despite a prompt search and activation of the facility's elopement code. The resident's admission assessment and elopement risk evaluation classified her as low risk for elopement, and a care plan for elopement risk was not initiated until after the incident. Although clinical documents from the transferring facility included an order for a wander alert device, and the resident had a history of leaving facilities, this information was not fully integrated into her care plan or supervision strategy upon admission. Staff interviews revealed that the MDS nurse did not review prior facility records for elopement risk and that the care plan was only created after the resident had already eloped. The facility's policies required evaluation of elopement risk upon admission and appropriate supervision based on resident condition. However, the resident was able to leave the facility without adequate supervision or intervention, resulting in her being missing for approximately ten hours before being located by law enforcement. The incident highlighted lapses in risk assessment, communication, and supervision that contributed to the resident's undetected exit.
Failure to Maintain Confidentiality of Residents' Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' health care information on two out of four medication carts. On the first-floor South medication cart, a computer screen displaying residents' health care information was left open and unattended. This was observed by a surveyor who then notified the Director of Nursing and a Registered Nurse, who subsequently closed the screen. The Director of Nursing acknowledged that screens should not be left open and unattended. On another occasion, a surveyor observed a similar incident on the third floor, where a Licensed Practical Nurse left a computer screen open on a medication cart while assisting a resident. The screen displayed residents' information and was visible to unauthorized individuals. The facility's policy on safeguarding electronic protected health information (e-PHI) requires that such information be protected from unauthorized access, which was not adhered to in these instances.
Deficiencies in Facility Maintenance and Safety Protocols
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies. A nightstand in a resident's room was found with a broken door, which the Assistant Director of Nursing (ADON) was unaware of until notified by the surveyor. The resident, who had a moderate cognitive impairment and required assistance with activities of daily living, was affected by this oversight. Additionally, the facility's third floor had four ceiling tiles with water stains and active dripping water, which were not addressed promptly despite previous roof repairs. The Maintenance Director was unsure why the tiles were discolored after being replaced, indicating a lack of effective communication and follow-up on maintenance issues. Furthermore, the facility failed to adhere to its policy regarding the cleaning of lint traps in the laundry room. During a tour, three lint traps were observed filled with lint, despite logs indicating they had been cleaned. A laundry aide admitted to signing the log before cleaning the traps, which contradicts the facility's policy of cleaning and then signing. This lapse in procedure was acknowledged by the Housekeeping Director, who stated that lint traps should be cleaned every one to two hours for fire prevention. These deficiencies highlight a failure in maintaining the facility's environment and ensuring adherence to established safety protocols.
Failure to Ensure Environment Free from Accident Hazards
Penalty
Summary
The facility failed to provide an environment free from potential accident hazards for one resident, as evidenced by the presence of bilateral side rails in the upward position with foam padding for a resident diagnosed with seizures. During the survey, the resident was observed in bed with the side rails padded, which was intended as a precaution for seizures. However, the presence of the side rails in the upward position was identified as a potential hazard. The resident's care plan, initiated in 2016, included interventions to pad side rails for safety due to the potential for injury related to seizures. The physician's order also specified the use of padded bilateral half side rails for seizure precautions. Despite these measures, the facility's policy on hazardous areas and equipment requires that any element in the resident environment with the potential to cause injury be identified and addressed, which was not adequately done in this case.
Inappropriate Use of Psychotropic Medication Without Documented Diagnosis
Penalty
Summary
The facility failed to ensure that psychotropic medications were used only to treat a documented condition for a resident. The resident was observed seated in a wheelchair, and their records indicated diagnoses of psychosis and anxiety disorder. However, the resident's Admission Minimum Data Set (MDS) and Preadmission Screening and Resident Review (PASRR) did not identify them as having a serious mental illness or intellectual disability. Despite this, the resident was prescribed Seroquel for schizoaffective disorder, a diagnosis not supported by the psychiatric note or other documentation. The care plan for the resident included goals and interventions related to the use of psychotropic medications, such as administering medication as ordered and consulting psychiatry as needed. However, the physician's order for Seroquel was based on an unsupported diagnosis of schizoaffective disorder. The facility's policy on psychotropic medication use clearly states that residents should not receive medications unless clinically indicated to treat a specific, documented condition. This discrepancy between the prescribed medication and the documented diagnoses constitutes a deficiency in the facility's adherence to its own policy and regulatory requirements.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to properly store medications on two out of four medication carts and one out of four medication rooms. On the third floor, surveyors observed an unattended medication cart with a pill crusher bag containing partially crushed pills left inside the pill crusher machine. The nurse responsible for the cart was on break, and the Assistant Director of Nursing was at the nursing station nearby but was occupied with a phone call. Additionally, on the first floor, a medication cart was found with an open drawer while unattended, and four expired tracheostomy kits were discovered in the medication room. Further observations revealed that a nurse on the third floor left a medication cart unlocked while retrieving an item, and another nurse on the first floor was found with a cart drawer ajar. The facility's protocol requires all medications to be locked inside the cart when unattended, but this was not adhered to in these instances. The Director of Nursing stated that the protocol is for medication carts to be kept locked when unattended, but did not provide a response when asked if medications should be left unattended.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near North Miami Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Lilac At Silver Palms | 1.2 mi | ★★★★★ | 13 | 0 |
| Serenity Bay Nursing And Rehabilitation Center | 1.4 mi | ★★★★★ | 14 | 0 |
| North Beach Healthcare And Rehabilitation Center | 1.5 mi | ★★★★★ | 11 | 0 |
| Hampton Court Nursing And Rehabilitation Center | 1.6 mi | ★★★★★ | 0 | 0 |
| North Dade Nursing And Rehabilitation Center | 1.7 mi | ★★★★★ | 9 | 0 |
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