Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 North Dade Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Uncovered trash bins were left unattended in a hallway, and multiple resident rooms and bathrooms had overflowing trash, sticky and dirty floors, foul odors, unflushed feces-like material, and visible debris. One resident with schizophrenia and major depressive disorder was observed with stained, torn, foul-smelling linens, and staff interviews confirmed routine cleaning practices, room prioritization for odors or garbage, and that some residents refuse cleaning or linen changes.
Repeated deficiencies were cited for F761, F684, F689, and F867 during a recertification survey. The facility’s QAPI policy stated it maintained a data-driven QAPI program, and the Administrator and DON described a monthly QAPI/QAA process using clinical meetings, dashboard data, and ad hoc reviews to identify issues and monitor outcomes, yet the cited problem areas remained repeated deficient practices.
Surveyors found resident medical information left visible and unattended at the J nursing station and an unattended computer screen with patient information visible at the East wing nursing station. Staff stated that HIPAA requires resident information to be kept private, computer screens to be locked when stepping away, and resident records not to be left visible or unattended; the facility policy also identifies leaving a secured application unattended while logged on as a violation.
Surveyors found unsafe supervision and hazard control failures when an overnight monitor near the double doors was observed seated with eyes closed and not responding, a housekeeping cart was left unlocked with keys in the door, and a resident who was dependent for smoking was observed smoking without the required apron. The resident had Metabolic Encephalopathy, an undetermined BIMS, and care plan and smoking screen documentation indicating a smoking apron was needed, but the smoking-area list did not reflect it.
Improper Indwelling Catheter Positioning and Drainage Bag Placement: Two residents with indwelling urinary catheters were observed with drainage bags and tubing positioned incorrectly. One resident’s bag was uncovered and on the floor, while another resident’s tubing lay over the bed rail above the bladder and the drainage bag touched the floor. Records showed both residents had catheter-related care plans and orders to maintain a closed drainage system and keep the bag covered.
An LPN administered crushed medication via a resident’s PEG tube without verifying tube placement or patency and without cleaning the valve port or connector tip before use. The resident had dysphagia, gastrostomy status, seizures, parkinsonism, respiratory failure, and tracheostomy status, and the facility’s orders and care plan required PEG placement and patency checks and flushing before and after meds.
Incorrect Oxygen Flow for Resident with Trach: A resident with a trach and respiratory failure was observed receiving O2 at 4 L/min instead of the ordered 5 L/min via humidified trach collar. The RT confirmed the order and adjusted the concentrator after the surveyor identified the discrepancy. Records showed the resident was dependent for all ADLs and received O2, suctioning, and trach care, and staff interviews indicated the RN believed the flow was at the ordered rate while a CNA stated she did not handle residents' O2 machines.
An unlocked, unattended med cart was observed on one wing, and medication was also left unattended at the bedside of a resident. An RN stated she left the medication while getting a gown, and another RN stated the cart was left open while helping a resident, even though the cart is supposed to be kept locked when away from it. The ADON stated meds are to be stored in a secure locked cart or med room, and facility policy required medications and biologicals to be labeled and stored per current state and federal regulations.
A resident with multiple medical conditions and moderate to maximal ADL assistance was found with a plugged-in electric water kettle on their bedside table, used to make coffee independently. Despite previous removal of a similar appliance, the resident was able to keep and use the kettle, contrary to facility policy requiring identification and mitigation of accident hazards.
A resident with diabetes and other medical conditions was not provided with a diet consistent with their prescribed LCS/NAS diet and personal food preferences. The resident received regular sugar and jelly instead of diabetic-appropriate alternatives at breakfast, and lunch trays were missing required items and included foods the resident disliked. Dietary staff confirmed that proper substitutions and diabetic-appropriate items were not provided as required by the resident's care plan and physician's orders.
A resident with diabetes and other medical conditions did not receive the prescribed LCS/NAS diet, as their meal trays included regular sugar and jelly instead of diabetic alternatives, and lacked required menu items such as a meat option, Vitamin C juice, and vegetables. Dietary staff confirmed the errors, and the resident's food preferences were not followed.
The facility did not effectively identify or address repeated deficiencies related to accident hazards and dietary menu compliance, despite holding regular QAPI meetings with leadership and department heads. These ongoing issues were cited again during a recertification survey, potentially affecting all residents.
A resident with cognitive impairments and exit-seeking behavior was found deceased in a facility closet after being documented as having left AMA. The facility failed to supervise the resident adequately, and staff did not witness the resident's exit. The facility's cameras were non-functional, and a thorough search was not conducted. Staff interviews revealed communication lapses and inadequate implementation of policies on neglect and AMA discharges.
A resident with moderate cognitive impairment and a history of wandering was found deceased in a locked closet after being allowed to leave the facility against medical advice. The facility failed to implement its abuse and neglect policy, resulting in inadequate supervision and a lack of proper documentation and notification. Staff interviews revealed communication and coordination issues in handling the situation.
A resident with a history of cognitive impairment and wandering behaviors left a facility undetected and was later found deceased in an unsecured storage closet. Despite being identified as high risk for elopement, the resident was not adequately monitored, and the facility's cameras were nonfunctional. Staff failed to communicate effectively and did not conduct a thorough search, leading to significant deficiencies in supervision and safety.
A resident with moderate cognitive impairment and exit-seeking behaviors left the facility AMA without proper monitoring or escort. The facility failed to implement a safe discharge process and did not follow policies for elopement risk and missing residents. The resident was later found deceased in a locked closet, highlighting deficiencies in supervision and communication among staff.
The facility failed to maintain accurate medical records and care plans for two residents. One resident's elopement risk was incorrectly documented, leading to a lapse in monitoring as the resident left against medical advice. Another resident's care plan included interventions for a wander management system not used by the facility, and staff were unaware of the resident's elopement risk. These documentation errors could affect any resident in the facility.
The facility's QAA Committee failed to address supervision deficiencies, resulting in repeated noncompliance and a resident's death. Despite monthly meetings and a system for tracking incidents, the committee did not implement effective corrective actions, leading to a severe incident where a resident with exit-seeking behavior was found deceased after being unaccounted for twelve days.
The facility's QAA Committee failed to implement effective corrective actions for repeated deficiencies, including maintaining a safe environment, accuracy of assessments, and quality of care. Despite monthly meetings, the facility was cited for the same issues, affecting 208 residents. The QAPI policy outlines leadership responsibilities, but repeated citations indicate a failure to address system gaps effectively.
The facility failed to maintain resident dignity and respect, as staff were observed standing while feeding a resident, delaying meal service for two residents, and using disrespectful terms. Additionally, a resident was left exposed without pants, and another without shoes or socks, indicating a lack of prompt attention to their dignity and privacy.
A resident's MDS was inaccurately coded, failing to reflect their smoking status, which led to the absence of a necessary care plan. The error was made by a former assistant, and the facility's policy requiring accurate MDS documentation for care planning was not followed.
A facility failed to accurately complete and update a Level 1 PASRR for a resident with Major Depressive Disorder, Anxiety Disorder, and Unspecified Psychosis. The initial PASRR only noted a psychotic disorder, and upon readmission, new diagnoses were not added, despite the resident receiving medications for these conditions. The facility's policy requires adherence to state and federal regulations for pre-admission screening, which was not followed.
A facility failed to develop a smoking care plan for a resident with multiple medical diagnoses, including anemia and hypertension. The care plan review showed no smoking care plan was created due to improper MDS coding by a former assistant, as reported by the MDS Coordinator.
A facility failed to provide appropriate skin care treatment for a resident with a dry and scaly right foot, despite a care plan that included skin inspections and moisturizers. The resident, with a history of hemiplegia and peripheral vascular disease, had no physician order for foot treatment at the time of the survey. The facility's policy on skin integrity was not followed, leading to a deficiency in care.
The facility failed to ensure resident safety by allowing access to shaving razors and leaving Soiled Utility/Biohazard rooms unlocked. Two residents were found with razors on their bedside tables, and staff entered biohazard rooms without using a code or key, indicating malfunctioning locks. These actions violated facility policies on accident prevention and waste management.
The facility failed to secure medications properly, with an unlocked medication cart observed and medications found at the bedside of two residents without physician orders. Staff acknowledged the need for secure storage, and the facility's policy mandates proper labeling and storage of medications.
A resident with multiple health conditions, including an amputated leg and diabetes, did not receive timely emergency dental services despite a physician's order for a dental consult due to a toothache. The facility failed to arrange the necessary dental care, and the resident experienced ongoing pain. The deficiency was due to poor communication and follow-through among staff, resulting in a delay in addressing the resident's dental needs.
A resident expressed dissatisfaction with the repetitive menu offerings, specifically the ham and cheese sandwich served on Sundays, which did not meet their preferences or cultural needs. Despite having a specialized diet due to medical conditions, the facility's menu planning failed to consider the resident's choices. The Dietary Manager acknowledged complaints and had requested menu changes for six months without success, highlighting a deficiency in meeting residents' dietary preferences.
The facility failed to maintain sanitary conditions in the nourishment pantry, as a microwave used for warming residents' food was found to be unclean with brown, dried substances and rust stains. This was confirmed by an LPN and the DON, affecting thirty-five residents on the J unit.
A microwave in the Nourishment Pantry Room on the J Unit Floor was found to be unclean and contained brown-like rust stains, as confirmed by an LPN and the DON. This affected thirty-five residents who ate orally. The facility's policy requires all essential equipment to be maintained in safe operating condition, which was not followed.
A resident with severe cognitive impairment was transferred to a hospital due to stroke symptoms, but the facility failed to document communication with the hospital or the resident's family. Staff interviews revealed confusion over discharge responsibilities and financial status, leading to the resident being discharged to another nursing home without follow-up from the original facility.
The facility's QAA Committee failed to address quality concerns related to maintaining accurate medical records, resulting in repeated deficiencies. Despite monthly meetings with key staff, the committee did not effectively identify and prioritize deficiencies or monitor corrective actions, leading to a recurrence of the citation for F842 - Resident Records ? Identifiable Information.
Unclean Environment, Overflowing Trash, and Soiled Linen
Penalty
Summary
The facility failed to maintain a safe, clean, sanitary, and homelike environment in the J hallway and in multiple resident rooms and bathrooms. On observation, three uncovered trash bins were left unattended in the J hallway. In several rooms, surveyors observed overflowing trash, sticky floor surfaces, black dust- or dirt-like debris, scattered paper, cups under beds, dirty and sticky side tables, foul odors, and visible liquid on the floor resembling urine. One bathroom contained feces-like material that had not been flushed, and another observation noted feces-like material dripping from the toilet seat into the toilet. The report also documented a brown-colored substance splashed on a wall, a toilet seat with a yellow stain, a bathroom floor that was sticky, and a wall behind one toilet with a broken tile and a hole. Resident #113 was observed with linens that had a hole, visible stains, and a foul odor. The resident’s clinical record showed a readmission with an initial admission date of 06/22/2022 and diagnoses of schizophrenia and major depressive disorder. The Quarterly MDS documented intact cognition. The MDS also indicated the resident required setup and cleanup assistance with eating, oral hygiene, and toileting hygiene, and supervision or touching assistance with bathing, dressing, footwear, and personal hygiene. The care plan identified a self-care deficit and included staff assistance with activities of daily living, setup of basic hygiene items, keeping items within easy reach, and providing assistance as needed. During interviews, the Housekeeping Aide stated she worked 7:00 AM to 3:00 PM, checked rooms three times daily, and cleaned rooms once per day with water and the facility-approved detergent; she also stated that when floors are sticky, the rooms are waxed. The Housekeeping Director stated housekeeping prioritized rooms needing more attention, including rooms with odors, food, or garbage accumulation, and said the floors had last been waxed on November 15, 2025. The Director of Maintenance stated rooms needing repair were tracked daily, maintenance staff worked Monday through Thursday, and tiles were checked weekly. The Infection Preventionist stated Resident #113 did not want anyone entering the room for cleaning, and the DON stated soiled or damaged linen are required to be removed and sent to laundry and are evaluated by housekeeping for disposal if necessary, while also noting that some residents refuse linen changes or removal of items from their rooms.
Repeated QAPI and Care Deficiencies
Penalty
Summary
The facility was cited during a recertification survey ending 09/04/2024 for repeated deficient practice related to F761-Lable/Store Drugs and Biologicals, F684-Quality of Care, F689-Free of Accident Hazards/Supervision/Devices, and F867-QAPI/QAA Improvement Activities. The survey findings noted that the facility had 210 residents at the time of the survey and that these deficiencies had also been identified during the recertification survey conducted from 09/01/2024 through 09/04/2024. Review of the facility’s QAPI policy dated 06/10/2021 stated that the facility was to maintain an effective, comprehensive, data-driven QAPI program focused on indicators of care outcomes and quality of life. During interview, the Administrator and DON stated that the QAPI/QAA team included leadership and management staff, met monthly, and used communication, morning clinical meetings, dashboard data, and ad hoc meetings to identify issues, determine root causes, and monitor outcomes. Despite this described process, the survey identified that the cited problem areas remained repeated deficient practices.
Failure to Secure Resident Information at Nursing Stations
Penalty
Summary
The facility failed to keep residents’ personal and medical records private and confidential at two nursing stations, East and J, out of three observed stations. At the J nursing station, surveyors observed paperwork containing residents’ medical information and names left visible and unattended. Staff A, the Overnight Supervisor RN, was informed of the concern and stated that the posting was a privacy violation and would be removed, and that all information is to be kept private. At the East wing nursing station, a staff member left a computer unattended with patient information visible on the screen. During interviews, Staff V, an LPN and nurse supervisor, stated that HIPAA privacy includes ensuring computer screens and medication carts are locked before stepping away and safeguarding resident information from unauthorized access or disclosure. The DON stated that patient privacy and confidentiality must be maintained at all times, computer screens must be closed or locked when not in use, and staff are not permitted to leave computers unattended while logged in. The facility policy titled HIPPA Policy dated 11/27/2019 listed leaving a secured application unattended while logged on as an example of a violation.
Unsafe Supervision, Unlocked Housekeeping Cart, and Missing Smoking Apron
Penalty
Summary
The facility failed to ensure an area was free from accident hazards and that residents received adequate supervision to prevent accidents. Surveyors observed Staff L, assigned as the overnight monitor near the double doors on the J hallway, seated in a chair with head down and eyes closed; the staff member did not respond when greeted twice and only looked up after being greeted again. When asked how residents could be properly monitored in that condition, Staff L replied, "Sorry." The ADON later stated that a monitor is assigned overnight at the double doors to prevent residents from exiting the building and that monitors are expected to sit by the door and remain awake. The facility also failed to keep a housekeeping cart locked while unattended. Surveyors observed a housekeeping cart with keys left in the door, and the housekeeping staff member stated the cart should be locked and the keys kept with staff. In addition, Resident#94 was observed smoking without an apron. Resident#94 was unable to verbalize answers to questions, had diagnoses including Metabolic Encephalopathy, and the MDS indicated tobacco use with a Brief Interview for Mental Status that was undetermined. The care plan identified the resident as a dependent smoker at risk for burn injury and included providing a smoking apron as needed, and the September and December 2025 smoking screens indicated the resident required a smoking apron. However, the smoking list in the smoking area did not include an apron for Resident#94, and staff interviews showed conflicting information about whether the resident’s smoking assessments and smoking list were correct.
Improper Indwelling Catheter Positioning and Drainage Bag Placement
Penalty
Summary
Provide appropriate care for residents with indwelling urinary catheters was not maintained for two residents when catheter tubing and drainage bags were observed improperly positioned. Resident #7 was found in bed with the urinary catheter drainage bag uncovered and on the floor, and the privacy bag was also on the floor. The resident stated he had had the catheter for one week and did not know why the bag was on the floor. A later observation again showed the drainage bag in a privacy bag touching the floor. Resident #7’s record showed a re-admission to the facility with an indwelling urinary catheter related to a sacral pressure ulcer. Physician orders directed catheter care every shift and as needed, monitoring for signs and symptoms of infection or blockage every shift, checking the stabilization device every shift and as needed, and keeping the drainage bag covered at all times. The care plan identified the resident as having an indwelling urinary catheter and being at risk for UTI and other catheter-related complications, with interventions to keep the catheter attached to bedside drainage, maintain a closed drainage system, and keep the drainage bag in a privacy bag at all times. Resident #93 was observed with indwelling catheter tubing positioned over the right-side bedside rail padding above the bladder, with dark red urine noted in the tubing, and the drainage bag in a privacy bag touching the floor. A later observation again showed the tubing and dignity bag touching the floor next to the bed. The resident’s record showed diagnoses including gastrostomy status and a sacral pressure ulcer, and the care plan identified the resident as having an indwelling catheter and being at risk for UTI and other catheter-related problems, with an intervention to attach the catheter to bedside drainage and maintain a closed drainage system intact.
PEG Tube Medication Administration Deficiency
Penalty
Summary
Staff failed to follow the facility’s medication administration procedure for a resident with a PEG tube during medication administration. During an observation, an LPN prepared crushed Bromocriptine mixed with water and administered it through the resident’s PEG tube, but did not check PEG tube placement or patency before giving the medication. The LPN also did not clean the valve port before use and did not clean the connector tip before reconnecting the feeding pump. The LPN later stated that she missed steps and only checked for tenderness and distention with her hands. The resident involved had diagnoses including aphasia following cerebral infarction, dysphagia following cerebral infarction, gastrostomy status, seizures, parkinsonism, respiratory failure, and tracheostomy status. The resident’s orders included checking the PEG tube for placement and patency every shift, flushing the PEG tube with 30 ml of water before and after medication administration, and continuous enteral feeding. The care plan also identified the resident as enterally fed and at risk for complications related to tube feeding, with interventions to check tube placement and patency every shift. The facility’s policy stated that enteral tube placement must be verified prior to administering any fluids or medication.
Incorrect Oxygen Flow for Resident with Trach
Penalty
Summary
Adequate respiratory care and services were not provided for one resident with a tracheostomy when oxygen was observed running at 4 L/min instead of the ordered 5 L/min during a trach care observation. The surveyor notified the RT, who confirmed the order was for 5 L/min and adjusted the oxygen concentrator to the prescribed rate. The resident had been admitted with diagnoses including tracheostomy and acute and chronic respiratory failure with hypoxia, and the quarterly MDS indicated the resident was dependent for all ADLs and received oxygen therapy, suctioning, and trach care. Record review showed a physician order for continuous trach oxygen at 5 L/min via trach collar with humidification and to maintain oxygen saturation over 92% every shift. The care plan included administering medication and/or oxygen as ordered. Staff interviews included an RN stating the oxygen was at 5 L/min when she came on shift and a CNA stating she did not touch residents' oxygen machines because that was not her responsibility. The facility policy stated residents needing respiratory care, including tracheostomy care and tracheal suctioning, would receive care consistent with professional standards and the care plan, and physician orders must be followed as prescribed.
Unsecured Medication Storage and Unattended Bedside Medication
Penalty
Summary
Drugs and biologicals were not securely stored in accordance with professional standards when one medication cart on the J wing was observed unlocked and unattended, and medication was also left unattended at the bedside of Resident #50. On 01/25/2026 at 6:35 AM, a transparent cup containing medication was observed on the side table next to Resident #50, and at 6:38 AM Staff B, RN stated the medication had been left there while she got a gown and that medications are stored in the medication cart to protect residents. On 01/26/2026 at 9:38 AM, an unlocked and unattended medication cart was observed, and at 9:43 AM Staff D, RN stated the cart had been left open while helping a resident and acknowledged that the medication cart is supposed to be kept locked when away from it. The Assistant Director of Nursing stated that medications are to be stored in a secure locked cart or medication room for safety of residents. Facility policy stated that all medications and biologicals are to be labeled and stored in accordance with current state and federal regulations.
Unsafe Use of Electric Appliance in Resident Room
Penalty
Summary
A deficiency was identified when a resident was observed with an electric water kettle plugged in on the bedside table in their room. The resident, who had a history of congestive heart failure, hypertension, and major depressive disorder, was cognitively intact according to their BIMS score but required moderate to maximal assistance with activities of daily living. The electric kettle was found during two separate observations, both times plugged in next to the bed, along with instant coffee and creamer. The resident stated that they used the kettle to make coffee because staff would not provide it when requested and asked that staff not be informed about the kettle. Interviews with facility staff revealed that this was not the first time the resident had brought in an appliance for making coffee; a previous coffee maker had been removed by staff during rounds. The facility's policy requires the environment to be free from accident hazards and for hazards to be identified, evaluated, and addressed. Despite this, the resident was able to keep and use the electric kettle in their room, which was not in accordance with the facility's stated procedures for preventing avoidable accidents.
Failure to Provide Diabetic-Appropriate Diet and Adhere to Dietary Orders
Penalty
Summary
A deficiency was identified when a diabetic resident did not receive a well-balanced diet that met their prescribed dietary needs. During breakfast, the resident was served a tray containing regular sugar and regular jelly, despite being on a Low Concentrated Sweets (LCS) and No Added Salt (NAS) diet. The tray also lacked a meat option, a choice of Vitamin C juice, sugar substitutes, and sugar-free jelly, all of which were specified in the resident's diet order. The resident, who has diabetes, hypertension, hemiplegia, protein-calorie malnutrition, and hyperlipidemia, reported not using the regular sugar or jelly and stated that diabetic-appropriate alternatives were not provided on his tray. At lunch, the same resident received a tray with black beans, rice, chopped baked chicken, unfrosted banana cake, and orange drink, but the tray was missing navy bean soup, buttered carrots or any vegetable, coffee or tea, and sugar substitutes, as outlined in the diet card. The resident's food preferences also indicated a dislike for rice and desserts or sweets, yet these items were present on the tray. Interviews with dietary staff confirmed that the resident should have received diabetic-appropriate items, such as sugar substitutes and diabetic jelly, and that substitutions for menu items were not properly communicated or executed, resulting in missing or incorrect food items. Record reviews showed that the resident's care plan and physician's orders required a therapeutic diet tailored to his medical conditions, including diabetes and risk for nutritional deficits. The facility's own policies mandated that residents receive nutritional care consistent with their assessments and dietary orders. However, observations and staff interviews revealed that the resident's dietary needs and preferences were not consistently met, leading to the identified deficiency.
Failure to Follow Prescribed Diabetic Diet and Menu for Resident
Penalty
Summary
The facility failed to ensure that prescribed menus were followed to meet the nutritional needs of a diabetic resident, resulting in the resident not receiving appropriate dietary items as ordered. During breakfast, the resident received a tray containing regular sugar and regular jelly, without the required sugar substitutes or diabetic jelly, despite being on a Low Concentrated Sweets (LCS) and No Added Salt (NAS) diet. The breakfast tray also lacked a meat option and a choice of Vitamin C juice, both of which were specified on the resident's diet card. The resident, who has diabetes, hypertension, hemiplegia, protein-calorie malnutrition, and hyperlipidemia, reported not using the regular sugar or jelly and not receiving diabetic alternatives on his tray. At lunch, the resident's tray did not include the planned navy bean soup, buttered carrots or any vegetable, coffee or tea, or sugar substitutes. Instead, the tray contained black beans, rice, chopped baked chicken, unfrosted banana cake, and orange drink. The lunch diet card specified that the resident should have received navy bean soup, baked chicken, rice, buttered carrots, banana cake, coffee or tea, and sugar substitute. The facility's menu substitution log indicated that buttered carrots were substituted with peas and banana cake with yellow cake without frosting, but peas were not present on the tray. Interviews with dietary staff confirmed that the resident should have received diabetic-appropriate items, including sugar substitutes and diabetic jelly, which were available in the facility. The dietary manager acknowledged that the resident was served regular sugar and jelly in error and that the planned vegetable substitution for lunch was not provided. The resident's food preferences also indicated a dislike for desserts, sweets, and rice, yet these items were included on his tray. The facility's assessment documented the need to provide individualized dietary requirements, but these were not met for this resident.
Failure to Identify and Correct Repeated Deficiencies in Accident Hazards and Menu Compliance
Penalty
Summary
The facility failed to implement effective plans of action to correctly identify and address quality deficiencies, specifically in the areas of accident hazards (F689) and ensuring menus meet resident needs and are followed (F803). Despite having a Quality Assurance and Performance Improvement (QAPI) policy in place since June 2021, which requires systematic review of data, root cause analysis, and corrective actions, the facility continued to have repeated deficient practices in these areas. During a recertification survey, these deficiencies were cited again, indicating ongoing issues with the facility's ability to recognize and resolve these problems. Records show that the facility held monthly QAPI committee meetings with attendance from key leadership and department heads, including the Administrator, Medical Director, DON, and others. However, the ongoing citations for the same deficiencies suggest that the QAPI process was not effective in identifying or correcting the underlying issues related to accident hazards and dietary menu compliance, potentially affecting all 211 residents in the facility at the time of the survey.
Neglect Leads to Resident's Death in Facility
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a tragic incident. The resident, who had a history of exit-seeking behavior and was at high risk for elopement, was not adequately supervised. Despite being identified as having cognitive impairments and being on medications for anxiety and agitation, the resident was able to leave the facility without staff noticing. The resident was later found deceased in a locked closet within the facility, 12 days after being documented as having left against medical advice (AMA). The facility's staff did not follow proper procedures for monitoring and supervising the resident, who had expressed a desire to leave and refused to sign an AMA form. The staff failed to ensure the resident's safety, as no one witnessed the resident leaving the facility, and there was a lack of communication among staff regarding the resident's whereabouts. The facility's cameras were not operational, and the staff did not conduct a thorough search of the facility, including the closet where the resident was eventually found. Interviews with staff revealed a lack of clarity and communication regarding the resident's status and the facility's policies for handling AMA discharges. The Nursing Home Administrator and Director of Nursing were unable to confirm if a comprehensive search was conducted within the facility. The facility's policies on abuse, neglect, and AMA discharges were not effectively implemented, contributing to the neglect of the resident's safety and well-being.
Failure to Implement Abuse and Neglect Policy Leads to Resident's Death
Penalty
Summary
The facility failed to implement its abuse and neglect policy, resulting in a resident going missing and later being found deceased in a locked closet. The resident, who had moderate cognitive impairment and a history of wandering behavior, was not adequately supervised or provided with a wander/elopement alarm. Despite exhibiting exit-seeking behaviors and expressing a desire to leave the facility, the resident was allowed to leave against medical advice (AMA) without proper documentation or notification to all relevant parties. The staff did not follow the facility's procedures for handling a missing resident or an AMA discharge. The resident was restless and anxious, and although staff attempted to redirect him, they did not ensure his safety. The resident's refusal to sign the AMA form was not properly addressed, and the staff failed to notify the physician or the resident's family promptly. The facility's policies required a thorough investigation and notification of law enforcement if a resident was missing, but these steps were not adequately followed. Interviews with staff revealed a lack of communication and coordination in handling the situation. The resident's behaviors and the potential risk of elopement were not effectively managed, and the facility's response to the resident's disappearance was delayed and insufficient. The failure to implement the abuse and neglect policy and the missing resident procedures contributed to the tragic outcome.
Failure to Supervise Resident with Exit-Seeking Behaviors
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident with exit-seeking behaviors, leading to a tragic incident. The resident, who had a history of altered mental status, cognitive communication deficit, and wandering behaviors, was not adequately monitored. Despite being identified as a high risk for elopement, the resident was able to leave the facility undetected and was later found deceased in an unsecured storage closet. The facility's cameras were nonfunctional, and the closet where the resident was found was not properly secured or monitored. The resident had been admitted with several medical conditions, including diabetes mellitus and a history of cerebral infarction, and was on medications for anxiety and agitation. On the day of the incident, the resident expressed a desire to leave the facility and was agitated. Although the staff attempted to educate the resident about the risks of leaving against medical advice (AMA), the resident refused to sign the AMA form and left the facility. The staff did not adequately supervise or monitor the resident's movements, and there was a lack of communication among staff members regarding the resident's departure. Interviews with facility staff revealed a lack of clarity and communication regarding the resident's status and the actions taken after the resident was reported missing. The facility's policies on elopement and AMA discharges were not effectively implemented, and there was a failure to conduct a thorough search of the facility, including the storage closet where the resident was eventually found. The facility's neglect in ensuring a safe environment and proper supervision resulted in the resident's death, highlighting significant deficiencies in the facility's operations and oversight.
Failure to Implement Safe Discharge Process and Supervision
Penalty
Summary
The facility's administrative staff failed to implement a safe discharge process for a resident who left the facility against medical advice (AMA). The staff did not monitor or escort the resident, who had a history of exit-seeking behaviors and was at high risk for elopement. The resident, who had moderate cognitive impairment and was at risk for falls, was not adequately supervised or provided with a care plan addressing wandering or elopement. This lack of supervision and failure to implement risk reduction measures led to the resident going missing from the facility undetected. The facility's policies on abuse prevention, elopement risk, and missing residents were not effectively followed. The resident's elopement risk assessment indicated a high risk for elopement, yet the staff did not take appropriate actions to mitigate this risk. The resident's intent to leave the facility was known, but the staff did not ensure the resident's safety or whereabouts after leaving. The facility's failure to conduct a thorough search and notify appropriate parties in a timely manner contributed to the resident's disappearance. The incident resulted in the resident being found deceased and decomposing in a locked closet days later. Interviews with the facility's administrator and staff revealed a lack of communication and coordination in handling the situation. The administrator was informed of the missing resident but was misled to believe the resident had left AMA without proper verification. The facility's neglect in providing necessary supervision and failing to adhere to established policies and procedures led to the tragic outcome.
Inaccurate Medical Records and Care Planning
Penalty
Summary
The facility failed to ensure the accuracy of residents' medical records in accordance with accepted professional standards, affecting two residents. For one resident, an Elopement Risk Assessment was incorrectly documented by the Assistant Director of Nursing (ADON) and later struck out by the Director of Nursing (DON). The ADON admitted to mistakenly placing the elopement risk assessment in the wrong chart while working on two charts simultaneously. This resident was initially assessed upon admission and was not at risk for elopement, with a score of three. However, a progress note indicated that the resident left the facility against medical advice without staff observation, highlighting a lapse in monitoring and documentation. Another resident was identified as being at risk for elopement, yet the care plan included interventions for a wander management system that the facility does not use. The resident's care plan noted behaviors of wandering without purpose, but the facility's attestation confirmed that no wander management systems were in place. A Licensed Practical Nurse (LPN) was unaware of the resident's elopement risk, although the resident was listed in the Elopement Book at the nursing station. The Maintenance Director confirmed that no checks for wander management systems were conducted, contradicting the care plan's interventions. These discrepancies in documentation and care planning have the potential to affect any resident in the facility. The inaccuracies in the medical records and care plans indicate a failure to maintain accurate and consistent documentation, which is crucial for ensuring resident safety and appropriate care. The facility's policies require that corrections to medical records be made by the individual who made the original entry, yet the errors in documentation were not adequately addressed, leading to potential risks for the residents involved.
Failure in Supervision Leads to Resident's Death
Penalty
Summary
The facility's Quality Assurance and Assessment (QAA) Committee failed to identify and address quality concerns effectively, leading to repeated deficiencies in providing adequate supervision to residents. The facility had a history of deficient practices related to supervision and accident hazards, as evidenced by multiple survey events where noncompliance was cited. In one severe incident, the facility was negligent in supervising residents with exit-seeking behaviors, resulting in the death of a resident who was found deceased in a locked room after being unaccounted for twelve days. This incident was classified as actual harm that is not immediate jeopardy. The facility's Quality Assurance Performance Improvement (QAPI) Program Policy and Procedure aimed to maintain a comprehensive, data-driven program focusing on care outcomes and quality of life. Despite having a QAA Committee that met monthly and included various interdisciplinary team members, the committee failed to implement effective plans of action to prevent such incidents. The facility's system for tracking adverse incidents and conducting root cause analyses did not prevent the repeated deficiencies, indicating a lack of effective oversight and corrective measures.
Repeated Deficiencies in Quality Assurance and Assessment
Penalty
Summary
The facility's Quality Assurance and Assessment (QAA) Committee failed to implement effective plans of action to correct identified quality deficiencies, as evidenced by repeated citations for the same issues. During a survey with an exit date of 08/01/24, the facility was cited for deficiencies that had been previously identified in a survey with an exit date of 03/24/2023. These deficiencies included issues related to maintaining a safe, clean, comfortable, and homelike environment (F584), accuracy of assessments (F641), PASRR screening for mental disorder/intellectual disability (F645), development and implementation of comprehensive care plans (F656), quality of care (F684), routine/emergency dental services (F791), and proper labeling and storage of drugs and biologicals (F761). Additionally, the facility was cited for deficiencies in QAPI/QAA improvement activities (F867). This pattern of repeated deficient practices has the potential to affect any of the 208 residents residing in the facility at the time of the survey. The QAA Committee, which includes the Administrator, Medical Director, Director of Nursing (DON), and other interdisciplinary team members, meets monthly to review departmental reports and discuss interventions. However, despite these meetings, the facility's history of repeated deficiencies suggests that the committee's actions have not been effective in addressing and correcting the identified issues. The facility's policy on Quality Assurance Performance Improvement (QAPI), implemented in June 2021, outlines the responsibilities of the governing body and leadership in ensuring the program is ongoing, adequately resourced, and effective in addressing identified concerns. However, the repeated citations indicate a failure to meet these policy guidelines, as corrective actions have not successfully addressed gaps in systems or been evaluated for effectiveness.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as evidenced by several observations and interviews. Staff were observed standing while feeding a resident, which is not a dignified manner of assistance. Additionally, two residents did not receive their meal trays until half an hour after their roommates, indicating a lack of timely service and potential neglect of their needs. Staff also referred to residents needing assistance with eating as 'feeders,' which is a disrespectful term that undermines the dignity of the residents. Further observations revealed that a resident was left in a wheelchair with no pants on, exposing their genitals in view of staff and other residents. Despite the resident's request for clothing, there was a delay in staff response, highlighting a lack of prompt attention to the resident's dignity and privacy. Another resident was seen propelling themselves in a wheelchair without shoes or socks, and it took several minutes before staff provided appropriate footwear. The facility's policy on promoting and maintaining resident dignity emphasizes treating each resident with respect and individuality. However, the actions and inactions observed during the survey indicate a failure to adhere to this policy, resulting in a deficiency in maintaining the dignity and respect of the residents involved.
Inaccurate MDS Coding Leads to Deficient Care Planning
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, leading to a deficiency in care planning. The resident, who was admitted on an unspecified date, had an Annual MDS indicating severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 5 out of 15. However, the MDS inaccurately recorded the resident's current tobacco use as 'No,' despite the facility having 56 residents who are smokers. This error was attributed to the MDS being coded by an assistant who is no longer employed at the facility. As a result, a care plan addressing the resident's smoking status was not developed. The facility's policy requires comprehensive and accurate MDS documentation to ensure proper care plan development, which was not adhered to in this case.
Failure to Update PASRR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure an accurate Level 1 Preadmission Screening and Resident Review (PASRR) was completed for a resident prior to readmission and did not revise the screening following admission. The resident, who was admitted with diagnoses including Major Depressive Disorder, Anxiety Disorder, and Unspecified Psychosis, had a PASRR completed by a hospital social worker that only noted a psychotic disorder. The PASRR did not indicate a need for a Level II evaluation, despite the resident's documented history of mental illness. Upon readmission from the hospital, new diagnoses of anxiety and depression were not added to the PASRR, although the resident was receiving medications for these conditions. The Assistant Director of Nursing (ADON) acknowledged that the initial PASRR only had a psychotic disorder checked off and that the anxiety and depression diagnoses were added after the resident's return from the hospital. However, the psychiatric physician did not update the PASRR to reflect these diagnoses. The resident's care plan included monitoring for drug-related side effects due to psychotropic medications, but the PASRR remained outdated. The facility's policy requires pre-admission screening and resident review in accordance with state and federal regulations, which was not adhered to in this case.
Failure to Develop Smoking Care Plan for Resident
Penalty
Summary
The facility failed to develop a smoking care plan for a resident who was reviewed for discharge care planning during a survey. The resident, who was admitted to the facility on an unspecified date, had medical diagnoses including anemia, hypertension, arthritis, cataracts, glaucoma or macular degeneration, and insomnia. A review of the care plan dated June 16, 2024, with a target completion date of September 14, 2024, revealed that the facility had not created a smoking care plan for the resident. An interview with the MDS Coordinator on July 31, 2024, indicated that the Minimum Data Set (MDS) was coded by an assistant who is no longer employed at the facility. The improper coding in the MDS was cited as the reason for the absence of a smoking care plan.
Failure to Provide Skin Care Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident's skin condition, specifically for a dry and scaly right foot. The resident, who was observed in bed with the right foot exposed, had a medical history that included hemiplegia, hemiparesis, and peripheral vascular disease. Despite a care plan that included interventions such as daily skin inspections and the use of moisturizers and barrier creams, there was no physician order for lotion or applications for the resident's feet at the time of the survey. The resident's skin condition was noted during a weekly skin audit, but no abnormalities were reported. Upon inquiry by the surveyor, a Licensed Practical Nurse confirmed the absence of any treatment orders for the resident's feet. The Assistant Director of Nursing was informed of the observation and acknowledged that the resident's lower extremities appeared dry. The facility's policy on skin integrity emphasized the provision of topical treatments for residents with skin impairments, yet this was not adhered to in the case of the resident's dry and scaly foot. This oversight highlights a deficiency in the facility's adherence to its own policy and the physician's orders regarding skin care management.
Safety Lapses in Resident Supervision and Biohazard Room Security
Penalty
Summary
The facility failed to ensure the safety of two residents by allowing access to shaving razors, which were observed on bedside tables. Resident #12, who is cognitively intact but has a self-care deficit due to impaired mobility, was found with an open toiletry bag full of razors on his overbed table. Despite being educated about safety and the need to store razors securely, the resident resisted staff intervention. Similarly, Resident #84, who requires substantial assistance for personal hygiene and is at risk for falls, was found with a shaving razor on the bedside table without staff supervision. Additionally, the facility did not maintain secure access to Soiled Utility/Biohazard rooms, which were found unlocked on multiple occasions. Staff members, including a CNA and a Floor Tech, were observed entering these rooms without using a code or key, indicating that the door locks were not functioning properly. The Environmental Supervisor later identified and fixed an issue with the door latch that prevented it from locking. The facility's policies on managing regulated medical waste and reporting accidents and hazards were not adhered to, as evidenced by the unsecured Soiled Utility/Biohazard rooms. The policy requires that these rooms be locked to prevent unauthorized access and ensure resident safety. The failure to secure these areas and manage resident access to potentially hazardous items like razors represents a significant oversight in maintaining a safe environment.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure that medications were secured and properly stored, as observed on the E Nursing unit. A medication cart was found unlocked and unattended, which was acknowledged by a registered nurse who stated that the cart should always be locked when unattended for residents' safety. Additionally, medications were found at the bedside of two residents without physician orders, including nasal spray, eye drops, and Ammonium Lactate Lotion for one resident, and Ammonium Lactate Lotion for another. The Assistant Director of Nursing confirmed that these residents did not have orders to keep medications at their bedside and stated that medications should be administered by staff. Staff members, including LPNs and CNAs, reported conducting rounds to check for medications at residents' bedsides, but did not observe any during their checks. The Director of Nursing stated that a staff member is assigned daily to clean drawers and remove unauthorized items, and reiterated that medication carts should be locked when unattended. The facility's policy requires that all medications and biologicals be labeled and stored according to state and federal regulations, ensuring safe and secure storage with limited access.
Failure to Provide Timely Emergency Dental Services
Penalty
Summary
The facility failed to provide emergency dental services for a resident who required a dental consult due to a toothache. The resident, who was admitted with multiple diagnoses including diabetes mellitus, hypertension, and an amputated right leg below the knee, had not seen a dentist since admission. Despite a physician's order for a dental consult on July 8, 2024, the consult was not scheduled, and the resident continued to experience dental pain. The resident was alert, oriented, and able to communicate her needs, yet the necessary dental services were not arranged in a timely manner. The deficiency was further compounded by a lack of communication and follow-through among the facility's staff. The Director of Social Services was unaware of the dental consult order, and the information was not properly communicated during staff meetings. The resident was eventually given Tylenol for pain management, but the delay in addressing the dental issue highlights a breakdown in the facility's process for ensuring timely and appropriate dental care. The resident's pain and the delay in receiving dental services were directly linked to the facility's failure to adhere to its policy of providing necessary dental services.
Failure to Meet Resident Dietary Preferences and Needs
Penalty
Summary
The facility failed to ensure that menus were developed and prepared to meet the choices, including cultural and ethnic needs, of a resident. This deficiency was identified for a resident who expressed dissatisfaction with the repetitive menu offerings, specifically mentioning the unappealing nature of receiving a ham and cheese sandwich on Sundays. The resident, who has a medical history including diabetes mellitus, hypertension, peripheral vascular disease, epilepsy, and an amputated right leg below the knee, was on a specialized diet that included low concentrated sweets, no added salt, and limited fat. Despite these dietary requirements, the resident's preferences and cultural needs were not adequately considered in the menu planning. The facility's weekly four-cycle menu showed a lack of variety, with the same meals being served repeatedly on Sundays. The Dietary Manager acknowledged receiving complaints from residents about the repetitive menu and had requested changes for six months without success. The menus, outsourced and approved by a dietitian, had not been updated despite correspondence between the Dietary Manager and the Registered Dietitian. The facility's assessment indicated a diverse patient population with individualized dietary needs, yet the menu failed to reflect this diversity, leading to dissatisfaction among residents.
Unsanitary Conditions in Nourishment Pantry
Penalty
Summary
The facility failed to ensure food was prepared under sanitary conditions, as evidenced by the unclean state of equipment in the nourishment pantry. During an observation of the J Unit Floor Nourishment Pantry Room, a microwave used to warm up residents' food was found to be unclean, with brown, dried substances and brown-like rust stains. This deficiency was confirmed through interviews with a Licensed Practical Nurse and the Director of Nursing, who both acknowledged the presence of rust stains in the microwave. This unsanitary condition was observed in one of three nourishment pantries and had the potential to affect thirty-five out of forty residents who eat orally on the J unit.
Microwave in Disrepair in Nourishment Pantry
Penalty
Summary
The facility failed to maintain a microwave in good repair, which was used for residents in the Nourishment Pantry Room on the J Unit Floor. During an observation, the microwave was found to be unclean, with brown, dried substances and brown-like rust stains. This condition was confirmed by a Licensed Practical Nurse (LPN) and later by the Director of Nursing (DON). The microwave's poor condition had the potential to affect thirty-five out of forty residents who were eating orally on the J unit at the time of the survey. The facility's policy on Safety Awareness, issued in March 2021, mandates that all essential mechanical, electrical, and patient care equipment be maintained in safe operating condition, which was not adhered to in this instance.
Failure to Maintain Accurate Medical Records and Follow-Up
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was transferred to a hospital. The resident, who had severe cognitive impairment and required extensive assistance for activities of daily living, was admitted with multiple diagnoses including diabetes mellitus, bipolar disorder, and dementia. On the day of the incident, the resident exhibited symptoms of a stroke and was transferred to a local hospital via emergency services. However, the facility did not document any communication with the hospital to confirm the resident's arrival or status, nor did they communicate with the resident's family or representative. Interviews with various staff members revealed a lack of clarity and responsibility regarding the resident's discharge and follow-up procedures. The Registered Nurse and Social Services Director indicated that the discharge planning was not properly executed, and the Marketing Director mentioned that there was no denial of insurance but a lack of available beds for the resident's return. The Admissions Director and Business Office Manager provided conflicting information about the resident's financial status and the referral process for readmission. Further investigation showed that the resident was admitted to the hospital and later discharged to another nursing home, without any follow-up from the original facility. The Director of Nursing, who was not employed at the time of the incident, confirmed that there were no notes indicating a follow-up call to the hospital. This lack of documentation and communication highlights the facility's failure to adhere to accepted professional standards for maintaining medical records and safeguarding resident-identifiable information.
Repeated Deficiency in Maintaining Accurate Medical Records
Penalty
Summary
The facility's Quality Assurance and Assessment (QAA) Committee failed to identify and address quality concerns related to maintaining accurate medical records, resulting in repeated deficiencies. The facility was cited for F842 - Resident Records ? Identifiable Information in March 2023 and again during the current survey. The facility's Quality Assurance Performance Improvement (QAPI) Program Policy and Procedure, issued in June 2021, outlines the establishment of a QAA Committee and a written QAPI Plan. The policy emphasizes the importance of a comprehensive, data-driven QAPI program focusing on care outcomes and quality of life indicators. However, the QAA Committee did not effectively implement these guidelines, leading to the recurrence of the deficiency. The QAA Committee meetings were documented to occur monthly, with attendees including the Administrator, Medical Director, Director of Nursing (DON), and other department heads. Despite these regular meetings, the committee failed to identify and prioritize quality deficiencies, systematically analyze underlying issues, and monitor the effectiveness of corrective actions. The Administrator confirmed that the committee's purpose was to address issues, implement special projects, and improve the facility. However, the repeated citation for maintaining accurate medical records indicates a lack of effective action and oversight by the QAA Committee.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 310 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near North Miami
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Maria Nursing Center | 0.7 mi | ★★★★★ | 4 | 2 |
| Pines Nursing Home | 0.7 mi | ★★★★★ | 0 | 0 |
| Biscayne Health And Rehabilitation Center | 0.7 mi | ★★★★★ | 9 | 0 |
| The Lilac At Silver Palms | 0.8 mi | ★★★★★ | 13 | 0 |
| Fountain Manor Health & Rehabilitation Center | 1.1 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.