Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Palm Garden Of Aventura during CMS and state inspections, most recent first.
A deficiency was cited when a nurse failed to wear a gown, as required by Enhanced Barrier Precautions, while administering IV therapy to a resident with an active infection and central line. Although the facility's policy and care plan specified the use of both gloves and gowns for such high-contact care, only gloves were used during the observed procedure. Staff interviews confirmed knowledge of the protocol, but it was not followed during this incident.
During a Life Safety tour, it was observed that 4 out of 30 ceiling tiles in the Mechanical room near the kitchen were broken or missing, violating NFPA 101 standards. The Maintenance Director acknowledged the deficiency, which was also discussed with the Administrator.
The facility failed to maintain its sprinkler system according to NFPA 101 standards, as observed during a Life Safety tour. The Post Indicator Valve was missing a lock, a critical component for system security. This deficiency was acknowledged by the Maintenance Director and discussed with the Administrator during the exit conference.
The facility failed to maintain its essential electric system generator as per NFPA 101 standards due to the absence of high mortality spare parts. This deficiency was observed during a Life Safety Survey tour, acknowledged by the Maintenance Director, and discussed with the Administrator.
The facility's laundry room was found to be unsanitary, with rusted washer bases, improper chemical storage, and drainage issues. The Director of Environmental Services acknowledged these concerns, which were contrary to the facility's cleaning policy.
Two LPNs in a facility signed off medications for residents before administration, contrary to policy. One LPN did so to familiarize herself with the regimen, while the other did so for a single medication via tube. The DON acknowledged the need for re-education despite prior training.
Two LPNs at the facility were observed signing off medications for two residents before administration, contrary to the facility's policy. One LPN claimed unfamiliarity with the rule, while the other cited the simplicity of the task as a reason. The DON confirmed that all nurses had been trained on proper procedures.
The facility's laundry room was found to be unsanitary, with chemicals improperly stored on the floor, rusted washer bases, and washers draining into a dirty sink. The Director of Environmental Services acknowledged these issues, which were contrary to the facility's cleaning policy.
A resident with a DNR order was subjected to CPR by staff who failed to verify the resident's code status, despite clear facility policies. The RN involved did not check the electronic medical records due to panic, leading to a breach of the resident's right to die with dignity. The incident was reported as neglect.
A resident with cognitive impairment and a history of elopement risk exited the facility undetected through a dining room door. Despite working alarms and a care plan addressing elopement risk, the resident was found in the parking lot by an LPN. The facility's failure to provide adequate supervision and ensure the effectiveness of the alarm system led to this deficiency.
Failure to Follow Enhanced Barrier Precautions During IV Therapy
Penalty
Summary
Surveyors identified a deficiency in the facility's infection prevention and control program related to the implementation of Enhanced Barrier Precautions (EBP) for a resident receiving intravenous (IV) therapy. During a medication administration observation, a registered nurse performed hand hygiene and donned gloves but failed to wear a gown as required by the facility's EBP policy when providing central line care. The nurse administered IV medication and handled the resident's IV site without the additional protective equipment mandated for residents under EBP. The resident involved had been admitted with a diagnosis of osteomyelitis of the vertebra and was receiving antibiotic therapy via IV for this condition. The care plan for this resident included interventions specifying the use of Enhanced Barrier Precautions due to the presence of an IV line, which is considered a high-contact area and a potential source of cross-contamination. Facility policy and staff interviews confirmed that both gloves and gowns are required for staff when providing care to residents under EBP, particularly during high-contact activities such as IV administration. Interviews with the risk manager and the nurse involved confirmed that the facility's protocol was not followed during the observed care. The risk manager stated that staff are educated to wear both gloves and gowns for residents under EBP, and signage and PPE caddies are used to support compliance. The nurse acknowledged awareness of the requirement but did not don a gown during the observed procedure, attributing the lapse to nervousness. This failure to adhere to established infection control protocols constituted the cited deficiency.
Plan Of Correction
The Nurse-Staff A was immediately reeducated by the Director of Quality Assurance on 7/15/2025 on enhanced barrier precautions (EBP) and the usage of Personal Protective Equipment (PPE) during medication administration via central line. Resident #2 is receiving IV antibiotic therapy, and enhanced barrier precautions are being observed during IV administration and other tasks requiring EBP. An audit was completed by the Director of Clinical Services on 7/18/25 of all current residents with central lines to ensure that enhanced barrier precautions were adhered to when administering IV medications. Licensed staff were re-educated by the Director of Education or designee starting on 7/21/25 on infection control practices to include enhanced barrier precautions and appropriate PPE while administering medication via central line. Weekly audits/observations will be conducted for 4 weeks, then monthly for 3 months, by the Director of Clinical Services or designee to ensure that licensed staff are adhering to enhanced barrier precautions and appropriate Personal Protective Equipment is worn during medication administration for residents with central lines. Findings of audits will be reported to QAPI to ensure ongoing compliance.
Ceiling Tile Deficiency in Mechanical Room
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 standards during a Life Safety tour conducted on April 22, 2025. Observations revealed that in the Mechanical room near the kitchen, 4 out of 30 ceiling tiles were either broken or missing. This deficiency was noted during the inspection at 12:36 pm, with the Maintenance Director present. The Maintenance Director acknowledged the findings during the staff interview conducted at the same time. These observations were also discussed and acknowledged by the Administrator during the exit conference. The report cites specific sections of NFPA 101 and NFPA 1 standards that were not met, indicating a failure to maintain the ceiling tiles in accordance with these safety codes.
Plan Of Correction
The 4 missing ceiling tiles were replaced by the Director of Plant Operations on 04/22/2025. An audit of the mechanical room was conducted on 04/21/2025 by the Director of Plant Operations and no other areas were missing ceiling tiles. The Regional Director of Plant Operations educated the Plant Operations department of LSC Section 18.3 and 19.3 Protection requirements to ensure compliance with protection NFPA 101. Monthly audits of the mechanical room will be completed by Plant Operations Director or designee to determine if there are any missing tiles. Findings will be taken to QAPI.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its sprinkler system in accordance with NFPA 101 standards. During a Life Safety tour conducted at 1:30 pm on April 22, 2025, it was observed that the Post Indicator Valve, which is a critical component of the sprinkler system, was missing a lock. This deficiency was identified during the inspection with the Maintenance Director present. The Maintenance Director acknowledged the missing lock during a staff interview conducted at the same time as the observation. This issue was also discussed and acknowledged by the facility's Administrator during the exit conference. The lack of a lock on the Post Indicator Valve indicates a failure to adhere to the required maintenance and testing protocols as outlined in NFPA 25, which governs the inspection, testing, and maintenance of water-based fire protection systems.
Plan Of Correction
The missing lock on the post indicator valve was replaced on 04/23/2025 by the Director of Plant Operations in accordance with NFPA 25. An audit of the post indicator valve was conducted on 04/22/2025 by the Director of Plant Operations and no other locks were missing. The Plant Operations Department was educated on maintenance and Testing K353 CFR(s): NFPA 101 Sprinkler System requirements by the Regional Director of Plant Operations. Monthly audits of the post indicator valve will be completed by the Plant Operations Director or designee to determine if there are any missing locks. Findings will be taken to QAPI.
Facility Lacks Essential Generator Spare Parts
Penalty
Summary
The facility failed to maintain its essential electric system generator in accordance with NFPA 101 standards. During a Life Safety Survey tour, it was observed that the facility did not have generator high mortality spare parts on the premises. This deficiency was identified during an inspection conducted at 4:24 pm on April 22, 2025, with the Maintenance Director present. The Maintenance Director acknowledged the absence of these critical spare parts during a staff interview conducted at the same time. This acknowledgment indicates that the facility was aware of the deficiency in maintaining the essential electric system generator as per the required standards. The deficiency was further discussed and acknowledged by the Administrator during the exit conference. The lack of generator high mortality spare parts suggests a failure in the facility's preparedness to maintain the essential electric system, which is crucial for ensuring the safety and well-being of the residents in the event of a power outage.
Plan Of Correction
Findings will be taken to QAPI. Spare parts were purchased by the Plant Operations Director on 05/15/2025 and is currently located on site. No residents were affected by this deficient practice. The Plant Operations Team was educated by the Regional Director of Plant Operations on 05/15/2025 on Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Quarterly audits will be conducted by Plant Operations Director or designee to ensure there is adequate supplies of mortality spare parts per NFPA 111. Results will be taken to QAPI. Spare parts were purchased by the Plant Operations Director on 05/15/2025 and is currently located on site. No residents were affected by this deficient practice. The Plant Operations Team was educated by the Regional Director of Plant Operations on 05/15/2025 on Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 113. Quarterly audits will be conducted by Plant Operations Director or designee to ensure there is adequate supplies of mortality spare parts per NFPA 111. Results will be taken to QAPI.
Laundry Room Sanitation Deficiency
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the laundry room, as observed during a tour conducted with the Director of Environmental Services and the facility's administrator. The inspection revealed several issues, including rusted washer bases, improper drainage of washers into a two-compartment sink with visible dirt and grime, and chemicals such as detergent, bleach, iron sour, and softener being stored directly on the floor. Additionally, the garbage can pallets were soiled, a large hole was present in the wall, and one washer had dry drainage residue with no clear source identified. The Director of Environmental Services, who had been in his position for two months, acknowledged the concerns during an interview. He confirmed the improper storage of chemicals on the floor instead of on a pallet, the rusty washer bases, and the unsanitary condition of the two-compartment sink used for washer drainage. The interview also highlighted the soiled condition of the garbage can pallets, the presence of a large hole in the wall, and the dry drainage residue on one of the washers. The facility's policy on laundry area cleaning, which outlines daily, weekly, and monthly cleaning processes, was reviewed. The policy includes daily sanitization of folding tables, linen shelves, and soiled linen hampers, as well as weekly sanitization of chemical boxes and plumbing fixtures. Despite these guidelines, the observed conditions in the laundry room indicated a failure to adhere to the established cleaning schedule, resulting in the identified deficiencies.
Plan Of Correction
The base of the washer was painted and the hole in the wall was repaired on 5/05/2025 by Environmental Services Director. The two-compartment sink was cleaned; the garbage can pallets were washed, and the residue was removed from the washer on 05/06/2025 by Environmental Services. The four chemicals—detergent, bleach, iron sour, and softener—have been elevated off the floor on a palate. No residents were affected by this deficient practice. The Environmental Services Director was educated on maintaining a clean and sanitary environment in the laundry room on 04/18/25 by the Executive Director. The laundry staff was in-service on 05/02/2025 by the Director of Clinical Services on following the cleaning schedule and using the TELS system to notify Plant Operations if repairs are needed. The Director of Environmental Services or Designee will conduct audits of the laundry room to ensure that washer bases are free from rust, no chemicals are stored on the floor, garbage can pallets, two-compartment sink, and laundry equipment are clean and free from residue. Audits will be conducted daily for 1 week, then weekly for 4 weeks, then every two weeks for 2 months, and finally monthly. Findings of audits will be presented at the monthly QAPI meeting to ensure ongoing compliance.
Medication Administration Deficiency
Penalty
Summary
The facility failed to adhere to pharmaceutical procedures and policies during medication administration for two residents. During an observation at 8:00 AM, an LPN was seen signing off medications for a resident before they were actually administered. Similarly, at 9:50 AM, another LPN signed off on a medication for a different resident prior to its administration. These actions were contrary to the facility's policy, which mandates that medications should only be signed off as given after they have been administered to the residents. Interviews with the involved staff revealed a lack of awareness and understanding of the correct procedures. The first LPN admitted to signing off on medications ahead of time to familiarize herself with the resident's medication regimen, indicating a misunderstanding of the proper protocol. The second LPN justified his premature signing off by stating it was only one medication being administered via a tube, suggesting a possible underestimation of the importance of following the correct procedure regardless of the situation. The Director of Nursing confirmed that all nurses had received in-service training on medication administration, yet acknowledged the need for re-education on the correct procedures. The facility's policy clearly states that staff should comply with applicable laws and the state operations manual when administering medications, highlighting a gap between policy and practice in this instance.
Plan Of Correction
Staff nurse A and B were immediately reeducated during the survey on pharmaceutical procedure and the facility's policy during medication administration and on signing the Medication Administration Record after administration of medication. Residents #4 and #50 are receiving medications as ordered according to pharmaceutical procedure and the facility's policy and have exhibited no negative outcome. An audit was conducted of current residents by the Director of Clinical Services to ensure that medications were administered prior to the administration record being signed. No issues were identified. Staff nurse A and B were immediately reeducated during the survey by the Director of Clinical Services on pharmaceutical procedure and the facility's policy during medication administration. Licensed Nurses were reeducated starting by the Director of Clinical Services on pharmaceutical procedure and the facility's policy during medication administration and not signing the medication record until medications have been administered. The Director of Clinical Services or Designee will conduct random audits of the medication administration record for 10 residents to determine if the medication administration record was signed prior to the administration of medication, daily x 4 then weekly for 4 weeks, then quarterly x 4. Findings of audits will be presented at the monthly QAPI meeting to ensure ongoing compliance.
Medication Administration Deficiency
Penalty
Summary
The facility failed to adhere to pharmaceutical procedures during medication administration for two residents. During an observation at 8:00 AM, an LPN was seen signing off medications for a resident before they were actually administered. Similarly, at 9:50 AM, another LPN signed off on a medication for a different resident prior to its administration. Both instances were confirmed through interviews with the involved staff members, who admitted to signing off medications prematurely. The LPNs involved provided explanations for their actions. One LPN stated that she was not informed that signing off medications before administration was not allowed and did so to familiarize herself with the resident's medication. The other LPN mentioned that he signed off on the medication early because it was only one medication being administered via a tube. The Director of Nursing confirmed that all nurses had received training on medication administration policies, which clearly state that medications should only be signed off as given after they are administered.
Plan Of Correction
Staff nurse A and B were immediately reeducated during the survey on pharmaceutical procedure and the facility's policy during medication administration and on signing the Medication Administration Record after administration of medication. Residents #4 and #50 are receiving medications as ordered according to pharmaceutical procedure and the facility's policy and have exhibited no negative outcome. An audit was conducted of current residents by the Director of Clinical Services to ensure that medications were administered prior to the administration record being signed. No issues were identified. Staff nurse A and B were immediately reeducated during the survey by the Director of Clinical Services on pharmaceutical procedure and the facility's policy during medication administration. Licensed Nurses were reeducated starting on by the Director of Clinical Services on pharmaceutical procedure and the facility's policy during medication administration and not signing the medication record until medications have been administered. The Director of Clinical Services or Designee will conduct random audits of the medication administration record for 10 residents to determine if the medication administration record was signed prior to the administration of medication, daily x 4 then weekly for 4 weeks, then quarterly x 4. Findings of audits will be presented at the monthly QAPI meeting to ensure ongoing compliance.
Laundry Room Sanitation Deficiency
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the laundry room, as observed during a tour with the Director of Environmental Services and the facility's administrator. The deficiencies included improper storage of chemicals such as detergent, bleach, iron sour, and softener, which were stored directly on the floor instead of on a pallet. Additionally, the washer bases were rusted, and the washers were draining into a two-compartment sink that had visible dirt and grime. The garbage can pallets were soiled, a large hole was observed in the wall, and one washer had dry drainage residue with no clear source identified. The Director of Environmental Services, who had been in his position for two months, acknowledged these concerns during an interview. The facility's policy on laundry area cleaning outlined a systematic approach to maintaining cleanliness, including daily, weekly, and monthly tasks. However, the observations indicated that these procedures were not being followed, leading to the unsanitary conditions noted in the report.
Plan Of Correction
The base of the washer was painted and the hole in the wall was repaired on 5/05/2025 by Environmental Services Director. The two-compartment sink was cleaned; the garbage can pallets were washed, and the residue was removed from the washer on 05/06/2025 by Environmental Services. The four chemicals—detergent, bleach, iron sour, and softener—have been elevated off the floor on a palate. No residents were affected by this deficient practice. The Environmental Services Director was educated on maintaining a clean and sanitary environment in the laundry room on 04/18/25 by the Executive Director. The laundry staff was in-service on 05/02/2025 by the Director of Clinical Services on following the cleaning schedule and using the TELS system to notify Plant Operations if repairs are needed. The Director of Environmental Services or designee will conduct audits of the laundry room to ensure that washer bases are free from rust, no chemicals are stored on the floor, garbage can pallets, two-compartment sink, and laundry equipment are clean and free from residue. Audits will be conducted daily for 1 week, then weekly for 4 weeks, then every two weeks for 2 months, and finally monthly. Findings of audits will be presented at the monthly QAPI meeting to ensure ongoing compliance.
Failure to Honor DNR Order Leads to CPR on Resident
Penalty
Summary
The facility failed to honor the advance directives of a resident with a Do Not Resuscitate (DNR) order, leading to the initiation of Cardiopulmonary Resuscitation (CPR) by staff. This incident involved a registered nurse (RN) who, upon finding the resident unresponsive with no vital signs, did not verify the resident's code status before starting CPR. The facility's policy clearly states that CPR should not be initiated for residents with a DNR order, yet this protocol was not followed, resulting in a breach of the resident's right to die with dignity. The resident in question had a documented DNR order signed by both the resident's son and the physician. The resident was admitted with chronic respiratory failure and was receiving oxygen therapy, suctioning, and tracheostomy care. Despite these clear directives and the resident's medical condition, the RN, in a state of panic, failed to check the electronic medical records for the resident's code status and proceeded with CPR, which was against the resident's wishes. Interviews with staff revealed a lack of communication and verification of the resident's code status during the emergency. Multiple staff members, including CNAs and LPNs, were involved in the CPR process without confirming the resident's DNR status. The Director of Nursing (DON) was informed of the incident and confirmed that the RN did not check the code status due to panic. This oversight was reported as neglect, as it did not align with the facility's policies and procedures regarding advance directives and code status verification.
Removal Plan
- Resident pronounced deceased in the emergency room by Hospital personnel.
- Nurse Practitioner was notified that Resident was transported to the Hospital.
- Notification of event to Department of Children and Family.
- Ongoing reoccurring training-Education on code status, DNR policy, abuse and neglect policy initiated for current staff. Ancillary team members and CNAs to understand their role during a code blue (taking notes, bringing crash cart, calling 911, clearing hallway for EMS).
- Resident's chart.
- Audit of medical records to validate DNR/CPR orders.
- Federal immediate report submitted with notification to DCF.
- Code books reviewed for accuracy (books located at each nursing station).
- The nurse involved in the incident was removed from the scheduled pending complete investigation.
- Current/ongoing, now on monthly cycle-Code blue drills to be performed as follows: every shift, then every other day on different shift, then weekly then monthly to include weekends and holidays until all nurses have attended a code blue drill with no deficiencies. Alternating different scenarios of code status to increase staff understanding.
- Medical Director notified of events and interventions.
- Crash carts audited.
- Nurses' CPR cards audited for validation.
- ADHOC meeting with Interdisciplinary Team (IDT) and Medical Director.
- Quiz presented to licensed nurses to validate knowledge on code status and procedures.
- New admissions/re-admission records to be reviewed daily in morning clinical meetings and on weekends by the Nursing Supervisor for accurate code status.
- Audit results and outcome of drills to be presented weekly at Ad HOC meetings. Then monthly in QAPI to determine the effectiveness of the plan and if revisions to be done as necessary.
- AHCA Federal five-day report completed.
- Submit adverse report if applicable.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a vulnerable resident, leading to an elopement incident. The resident, who was cognitively moderately impaired and dependent on a wheelchair, exited the facility undetected through the first-floor dining room door. The incident occurred despite the facility's policy and procedure for managing missing residents and elopements, which was not effectively implemented in this case. The resident was found in the parking lot by an LPN who was on her break. The resident expressed that he was going to post a letter and was returned to the facility without resistance. The resident's care plan indicated a history of elopement risk with wandering behavior, yet the interventions in place were insufficient to prevent the incident. The resident's cognitive impairment and dependence on a wheelchair were documented, but the facility did not ensure the necessary supervision to prevent the elopement. Interviews with staff revealed that the alarms on the exit doors were in working condition, but the incident still occurred. The CNA assigned to the resident had last seen him around 7:30 PM, shortly before the elopement. The facility's failure to monitor the resident adequately and ensure the effectiveness of the alarm system contributed to the deficiency, as the resident was able to leave the premises without detection.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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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) |
|---|---|---|---|---|
| Vi At Aventura | 1.4 mi | ★★★★★ | 0 | 0 |
| Regents Park At Aventura | 1.6 mi | ★★★★★ | 6 | 0 |
| Kindred Hospital South Florida Hollywood | 2.6 mi | ★★★★★ | 0 | 0 |
| North Beach Healthcare And Rehabilitation Center | 2.8 mi | ★★★★★ | 11 | 0 |
| Serenity Bay Nursing And Rehabilitation Center | 3 mi | ★★★★★ | 14 | 0 |
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