Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Nspire Healthcare Miami Lakes during CMS and state inspections, most recent first.
Failure to protect resident confidentiality was cited after surveyors observed an unattended med cart computer screen on the 100-wing with residents' information visible and a posting with residents' medical information on a bulletin board in front of Unit 1. An RN stated the screen should be closed or put to sleep when away from the cart, and the DON stated the laptop should be closed or locked and that the posting should not have been displayed because it contained residents' medical information.
A resident with a right-hand contracture and cognitive impairment was observed multiple times without the ordered splint in place, despite the care plan and therapy evaluation indicating splint use for the contracted hand. In a separate issue, a resident with ESRD and dialysis needs did not receive the ordered phosphate binder before dialysis, even though the care plan directed medications be given as ordered by the MD.
A resident with hemiplegia, diabetes, morbid obesity, moderate cognitive impairment, and impaired skin integrity did not receive ordered care as documented. The resident’s right lower leg dressing remained in place beyond the ordered every-other-day schedule, and the resident’s contracted right hand had no splint in place during repeated observations. Staff and the DON acknowledged the dressing change was overdue, while therapy records showed a splint had been recommended for the hand contracture but was not yet available.
Unlocked housekeeping carts containing hazardous chemicals were found on two wings after staff left a cart unattended and another cart was observed with a broken latch. The Housekeeping Director stated carts are to be locked when unattended, and staff acknowledged the carts should be kept locked because the contents could harm residents.
Kinked Urinary Catheter Tubing: A resident with an indwelling urinary catheter was observed in bed with the catheter tubing coiled and kinked, preventing urine from flowing freely. The resident had a history of UTI, urinary retention, neurogenic bladder, and moderate cognitive impairment, and facility staff confirmed that catheter tubing should be kept straight to avoid obstruction and back flow.
Infection control was cited when a resident’s toothbrush was observed in a shared bathroom instead of being stored in a plastic bag in the drawer as staff described. The resident had cerebral infarction, severe cognitive impairment (BIMS 3), and needed set up or clean up assistance for oral hygiene. The DON and Infection Preventionist stated personal items, including toothbrushes, are to be stored in plastic bags in the drawer for infection control purposes.
The facility failed to maintain sanitary conditions in food preparation areas, affecting nearly all residents. Observations revealed brown stains on convection oven doors, a missing thermometer in the Unit 2 Pantry Freezer, and an unclean microwave in the Unit 1 Pantry. These issues were confirmed by the Certified Dietary Manager and the DON.
A facility failed to maintain a resident's dignity during meal assistance when an RN stood while assisting a resident with breakfast, contrary to the protocol requiring staff to be seated at eye level. The resident, with severe cognitive impairment, required setup and cleanup assistance for eating. The RN, who started in July 2023, was unaware of the protocol and had not received relevant in-service training. The facility's policy mandates staff to assist residents by positioning them comfortably and being seated during feeding.
A resident's MDS was inaccurately coded, omitting the use of hearing aids despite daily use and observations confirming their presence. The resident, diagnosed with dementia, had a care plan addressing hearing difficulties, yet the MDS did not reflect this. The Social Services Director acknowledged the error, highlighting a lapse in following the facility's MDS assessment policy.
The facility failed to implement care plans for two residents, leading to deficiencies in their care. One resident with muscle weakness did not consistently receive a prescribed splinting device, and staff were unclear about its application. Another resident with a skin tear did not receive timely treatment as ordered, with a lack of documentation and awareness among staff. These issues highlight a failure in communication and adherence to care plans.
The facility failed to prevent catheter-related injuries for two residents, as their catheter tubing was observed touching the floor, contrary to care plans. Additionally, a resident's prescribed wound care treatment for a skin tear was not implemented timely, with a delay of several days before treatment began. These deficiencies indicate lapses in following care protocols and physician orders.
The facility's QAA Committee failed to implement an effective plan to address a repeated deficiency related to F641, concerning the accuracy of assessments. Despite monthly meetings and a comprehensive QAPI program, the committee did not resolve the issue, affecting the care quality for 115 residents.
The facility failed to maintain essential kitchen equipment, including a convection oven, food steamer, and gas range stove, in good repair and cleanliness, potentially affecting residents' food safety. Observations revealed brown stains on the oven, a non-functional steamer, and a partially working stove. Additionally, the Unit 1 Pantry microwave was found unclean with rust-like stains, confirmed by the DON.
Failure to Protect Resident Confidentiality
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when surveyors observed an unattended computer screen on the 100-wing medication cart with residents' information visible and a document containing residents' medical information posted on the bulletin board in front of Unit 1. During the observation, Staff B, RN stated that the computer should be closed or the screen put to sleep when away from the cart for privacy. The DON later stated that nurses are to close the laptop completely or lock the screen when away from the cart to protect residents' information. The DON also acknowledged that the posting on the bulletin board should not have been displayed because it contained residents' medical information. The facility policy titled HIPAA Security Measures stated that the facility is to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of residents' identifiable information and/or records in electronic format.
Failure to Follow Care Plans for Splint Use and Dialysis Medication
Penalty
Summary
The facility failed to ensure that a resident with a right-hand contracture received care in accordance with the comprehensive person-centered care plan. The resident had diagnoses including hemiplegia and hemiparesis affecting the right dominant side, and the annual MDS dated 1/15/2026 showed moderate cognitive impairment with a BIMS score of 7 out of 15. The care plan, initiated on 08/23/2023 and addressing skin integrity, ADL self-care deficits, and pain risk, included use of a right-hand splint device. However, observations on 03/09/2026 and again on 03/11/2026 showed the resident in bed with the right hand contracted and no splint device in place. During an observation with the surveyor, the resident was unable to open the right hand. Staff stated the resident’s right hand was weak, that range of motion was provided at times, and that a splinting device was not ordered, while therapy documentation showed the resident had been evaluated and a splint was recommended but had not yet arrived. The facility also failed to administer a phosphorus binding agent in accordance with another resident’s dialysis care plan. The resident had end stage renal disease and a physician’s order dated 8/13/25 for calcium acetate 667 mg, two tablets by mouth before meals for hyperphosphatemia. The care plan for renal failure, revised on 04/15/2025, included giving medications as ordered by the physician. On 03/11/2026 at 7:10 AM, an RN stated that no medications were given before dialysis. The resident was observed eating breakfast at 7:09 AM and later seated in the room consuming lunch independently.
Failure to Follow Wound Dressing and Splint Care Orders
Penalty
Summary
The facility failed to ensure that Resident #109 received treatment and care in accordance with orders and professional standards of practice. Resident #109 was re-admitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, type 2 diabetes, and morbid obesity. The resident’s annual MDS showed a BIMS score of 7, indicating moderate cognitive impairment, and no ulcers, wounds, or skin problems were noted at that time. The care plan identified impaired skin integrity related to fragile skin and a history of a gastrostomy tube, and the physician’s order required Xeroform petroleum patch dressing changes to the right lower leg every other day for an open area. Observations showed a dressing dated 3/6 on the resident’s right lower leg on 3/9 and again on 3/9 later that day, despite the order for every-other-day changes. Staff B, RN stated the dressing was scheduled to be changed every other day by the floor nurse, and the DON stated the dressing should have been changed on Sunday. The resident also had a contracted right hand with no splint device in place during multiple observations. The care plan included a right hand splint device to be used, and an interdisciplinary therapy screen dated 2/26/26 stated the resident was screened for right hand contracture and would benefit from a splint, with OT evaluation upon delivery of the splint. Staff B, RN stated a splinting device was not ordered, while the PT Director later presented paperwork showing the splint had been recommended but had not arrived yet.
Unlocked Housekeeping Carts with Hazardous Chemicals
Penalty
Summary
The facility failed to ensure a safe environment on the 100 and 300 wings by leaving housekeeping carts containing hazardous chemicals unattended and unlocked. During an observational tour on 03/09/2026 at 11:15 AM, Staff D was seen walking away from the housekeeping cart on the 100 wing and leaving it unlocked while going down the hall. When the cart was inspected, it was found to contain hazardous chemicals. The Housekeeping Director later stated that all housekeeping carts are to be locked when unattended for resident safety. An inspectional tour with the Housekeeping Director at 11:35 AM found the 300-wing housekeeping cart unlocked and its latch broken. Staff D later stated the cart should be kept locked for resident safety and acknowledged leaving it unlocked. Staff E stated the cart should be locked because there are liquids inside that can harm residents, and said the latch had broken that morning. On follow-up interview, Staff E stated the latch on the housekeeping cart had broken again. The facility policy titled Care, Cleaning and Storage of Equipment stated environmental services cleaning carts are to be cared for, cleaned, and properly stored to ensure safety and infection prevention.
Kinked Urinary Catheter Tubing
Penalty
Summary
Provide appropriate care for residents with indwelling urinary catheters was not ensured for one resident when the urinary tubing was observed coiled and kinked, preventing urine from flowing freely. On 03/09/2026 at 9:55 AM, the resident was seen in bed with no apparent distress, and the catheter tubing was noted to be kinked. Staff B, RN, was informed at 9:59 AM and stated that urinary tubing should allow free flow of urine to prevent back flow that can cause infection. Resident #100 had a history that included UTI, neuromuscular dysfunction of the bladder, and retention of urine, and was re-admitted with an indwelling catheter. The resident’s MDS indicated moderate cognitive impairment and an indwelling catheter, and the care plan and physician’s order addressed the catheter for urinary retention and neurogenic bladder, with instructions to change it as needed for obstruction or blockage. Facility records also showed the resident had started an oral antibiotic for UTI on 12/11/25. The DON and infection control preventionist stated that catheter tubing should be positioned straight to prevent obstruction and return of urine to the bladder, and the facility policy stated to avoid kinks or obstruction in tubing.
Infection Control: Toothbrush Stored Improperly
Penalty
Summary
Provide and implement an infection prevention and control program was cited after surveyors observed a toothbrush belonging to Resident #34 in a shared bathroom rather than stored in a plastic bag in the drawer as described by facility staff. On 03/19/2026 at 10:06 AM, Resident #34 was observed in bed with no apparent distress, and a toothbrush was seen in the bathroom. On 03/09/2026 at 11:22 AM, a CNA identified the toothbrush as belonging to Resident #34 and stated that toothbrushes are stored in a plastic bag and kept in the drawer. Record review showed Resident #34 was re-admitted with a diagnosis including cerebral infarction. The quarterly MDS dated 12/5/2025 indicated a BIMS score of 3, severe cognitive impairment, and a need for set up or clean up assistance for oral hygiene. The care plan initiated on 10/06/2023 stated the resident had an ADL self-care performance deficit related to discharge from the hospital and required personal hygiene/oral hygiene care to maximize independence. The DON and Infection Preventionist both stated that personal items, including toothbrushes, are to be stored in a plastic bag in the drawer for infection control purposes, and the facility policy stated infection control practices are intended to maintain a safe, sanitary, and comfortable environment and help prevent and manage transmission of diseases and infections.
Sanitation Deficiencies in Kitchen and Pantry Areas
Penalty
Summary
The facility failed to ensure food was prepared under sanitary conditions, as evidenced by several observations during a survey. The initial kitchen tour revealed brown stains on the inside and outside of the convection oven doors, which were confirmed by the Certified Dietary Manager, Senior Food Service Director, who stated that the oven is cleaned weekly. Additionally, the Unit 2 Pantry Freezer was found to lack a thermometer, which is against the facility's policy that requires an accurate thermometer to be maintained inside the refrigerator and freezer. This was confirmed by the Director of Nursing (DON) during an observation and interview. Furthermore, the Unit 1 Pantry Microwave, used to warm up residents' food, was observed to be unclean, with brown, dried substances and brown-like rust stains inside. This was also confirmed by the DON during an observation and interview. These deficiencies have the potential to affect one hundred and fourteen out of one hundred and fifteen residents who eat orally at the facility.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to uphold the resident's right to dignity during meal assistance for one resident out of twelve who required such assistance. This deficiency was observed when a registered nurse (RN) was seen standing while assisting a resident with breakfast, contrary to the facility's protocol, which requires staff to be seated at eye level with the resident during meals. The RN, who started working at the facility in July 2023, admitted to not being sure about the protocol and not having received any in-service training regarding this procedure. The resident involved had a severe cognitive impairment, as indicated by a Brief Interview of Mental Status (BIMS) score of 3, and required setup and cleanup assistance for eating. The resident was on a therapeutic diet with no significant weight changes noted. The facility's policies and procedures, effective since November 2018 and revised in September 2023, clearly state that nursing personnel should assist residents with feeding by positioning them comfortably and transferring them to a straight-back chair if appropriate. Despite these guidelines, the RN's actions did not align with the established protocol, as confirmed by the Director of Nursing.
Inaccurate MDS Coding for Resident's Hearing Aids
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, identified as Resident #34, who was observed using hearing aids daily. Despite the resident's regular use of hearing aids, the Medicare 5-day MDS with a reference date of 7/8/24 did not include this information in Section B. Observations by surveyors on 8/26/24 and 8/28/24 confirmed the presence of hearing aids, either on the nightstand or in use by the resident. The resident, who has a diagnosis of dementia, was noted to have hearing difficulties, as indicated by a physician's order dated 6/11/24 and a care plan initiated on 6/10/24 addressing hearing-related self-care deficits. The Social Services Director acknowledged on 8/29/24 that the MDS was incorrectly coded, confirming that Section B should have included the use of hearing aids. The facility's policy on MDS assessments, effective since 11/30/2014 and revised on 9/25/2017, mandates comprehensive and accurate assessments at least every three months. The policy requires designated interdisciplinary team members to complete specified sections of the MDS, signing an attestation statement to ensure accuracy. This oversight in coding reflects a failure to adhere to the established procedures for accurate resident assessments.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement care plans for two residents, leading to deficiencies in their care. Resident #302, who was diagnosed with muscle weakness and left side hemiplegia, had a physician's order for a left resting hand splint and electrical stimulation to facilitate movement. However, the splinting device was not consistently applied as per the care plan. Observations showed the splint was often not in use, and staff were unclear about the frequency and responsibility for its application. The resident expressed discomfort with the splint, and there was no documentation of refusal or removal of the device, indicating a lack of communication and adherence to the care plan. Resident #252 had a care plan addressing potential skin integrity issues, with specific interventions for a skin tear on the left ankle. Despite a physician's order for daily treatment with Mupirocin ointment, the treatment was not documented or administered until several days after the order was given. The Director of Nursing and the wound care nurse were unaware of the initial order, and the treatment administration record lacked documentation for the prescribed care, highlighting a failure in implementing the care plan and ensuring timely treatment. These deficiencies were identified through observations, interviews, and record reviews, revealing a lack of coordination and communication among staff regarding the residents' care plans. The facility's policy required an individualized, person-centered care plan developed by an interdisciplinary team, but the execution of these plans was inadequate, resulting in unmet needs for the residents involved.
Failure to Prevent Catheter-Related Injuries and Delay in Wound Care
Penalty
Summary
The facility failed to implement necessary precautions to prevent catheter-related injuries for two residents with indwelling catheters. Resident #352 was observed with the catheter tubing touching the floor while propelling herself in a wheelchair. Despite having orders to monitor the catheter per shift and use a leg strap to anchor it, these precautions were not followed, leading to potential infection control issues. Similarly, Resident #21 was observed on two occasions with the catheter tubing on the floor, despite care plans indicating the need to position the catheter bag and tubing properly to prevent trauma. Additionally, the facility did not timely implement a prescribed treatment for a skin tear on Resident #252's left ankle. The wound care note dated 06/14/2024 indicated a treatment plan, but the Treatment Administration Record showed no documentation of treatment until 06/21/2024. This delay in treatment was acknowledged by the Director of Nursing, who confirmed that the treatment was not implemented as ordered by the physician. The report highlights deficiencies in adhering to care plans and physician orders, which are critical for preventing complications and ensuring resident safety. The failure to maintain catheter tubing off the floor and the delay in wound care treatment reflect lapses in the facility's compliance with established care protocols.
Repeated Deficiency in Accuracy of Assessments
Penalty
Summary
The facility's Quality Assurance and Assessment (QAA) Committee failed to implement an effective plan of action to address a repeated deficiency related to F641, which concerns the accuracy of assessments. This deficiency was identified during a survey and has the potential to affect all 115 residents residing in the facility. The facility had been previously cited for this deficiency in 2023, indicating a repeated failure to address the issue adequately. The QAA Committee, which includes various interdisciplinary team members such as the Administrator, Medical Director, and Director of Nursing, meets monthly to review and address quality deficiencies. However, despite these meetings, the committee did not demonstrate an effective corrective plan to resolve the identified deficiency. The facility's policy on Quality Assurance Performance Improvement (QAPI) outlines procedures for identifying quality deficiencies and developing corrective actions. The policy allows the facility to choose methods such as Plan, Do, Study, Act or Performance Improvement Projects to address deficiencies. Despite having a comprehensive, data-driven QAPI program, the facility's efforts to correct the deficiency related to F641 were insufficient, as evidenced by the repeated citation. The report highlights that the QAA Committee's meetings and discussions did not result in effective actions to ensure the accuracy of assessments, which is crucial for the quality of care and quality of life of the residents.
Deficiencies in Kitchen Equipment Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain essential kitchen equipment in good repair and cleanliness, which could potentially affect the majority of residents who consume food orally. During an initial kitchen tour, surveyors observed brown stains on the convection oven doors, indicating inadequate cleaning despite a weekly cleaning schedule. The Certified Dietary Manager confirmed the presence of these stains. Additionally, the food steamer was found to be non-functional, as it kept shutting off, and only one side of the gas range stove was operational. These issues were confirmed by staff interviews, highlighting a lack of prompt maintenance and repair. Furthermore, the Unit 1 Pantry microwave, used to warm residents' food, was found to be unclean, with brown dried substances and rust-like stains. This was confirmed by the Director of Nursing during an observation and interview. The facility's policy on maintenance, which requires preventive maintenance and prompt repair actions, was not adhered to, leading to these deficiencies in equipment cleanliness and functionality.
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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 Hialeah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glades West Rehabilitation And Nursing C | 3.2 mi | ★★★★★ | 3 | 0 |
| Palmetto Care Center And Rehab | 4 mi | ★★★★★ | 8 | 0 |
| Villa Maria West Skilled Nursing Facility | 4.6 mi | ★★★★★ | 2 | 0 |
| Susanna Wesley Health Center | 4.9 mi | ★★★★★ | 0 | 0 |
| Memorial Manor | 5.4 mi | ★★★★★ | 1 | 0 |
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