Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Palmetto Subacute Care Center during CMS and state inspections, most recent first.
A resident with respiratory diagnoses was observed receiving oxygen at 3.5 LPM by NC instead of the ordered 2 LPM PRN for SOB or O2 sat below 92%. The record showed the resident was receiving oxygen therapy, and staff interviews confirmed that oxygen and nebulizer treatments were to be given according to the physician’s order; the resident was later observed in a wheelchair with no oxygen in use.
Improper Storage of Medications and Topical Products: Surveyors observed ointments, lotions, creams, and even a pack of pills left at the bedside or on overbed tables for several cognitively intact residents with varying ADL needs. Staff stated prescribed topicals belonged on the med cart and personal lotions/creams in labeled resealable bags in bedside drawers, but the items were found stored in resident rooms instead of secured as described in the facility policy.
QAA committee failed to show an effective plan of action was implemented to correct a repeated F761 deficiency involving label/store drugs and biologicals. Surveyors cited the facility because drugs and biologicals were not stored and labeled properly, and the same issue had already been cited on the prior recertification survey. The DON stated the monthly QAPI process reviewed prior month data, department reports, and QAPI log entries for discussion of interventions.
Improper Storage of Cleaning Supplies in Resident Room: Cleaning supplies, including dishwashing liquid soap and disinfectant spray, were observed stored in a resident’s room above the handwashing sink and remained there during a later check while the resident was away. The resident had a BIMS score of 15 and diagnoses including aftercare following joint replacement surgery and unilateral primary osteoarthritis of the left knee. Staff stated such items should not be kept in resident rooms, and the facility policy required cleaning supplies to be stored separately.
A resident with dementia and psychiatric conditions exited the facility undetected by following visitors through the front door while staff were occupied, despite having expressed a desire to leave earlier in the evening. The resident was not identified as at risk for elopement, and his care plan lacked interventions for wandering prevention. Staff only realized the resident was missing after being notified by his family, resulting in a delayed response and a failure to provide adequate supervision.
Expired disinfectant wipes were found on two floors of the facility, with one container on the second floor and two on the third floor having expired dates, and two others with illegible dates. The Housekeeping Director admitted to refilling old containers without updating expiration dates, causing confusion among staff. CNAs reported checking expiration dates and notifying maintenance of expired wipes. The facility's policy emphasizes the need for proper infection control oversight.
The facility failed to properly label and store medications, discard expired supplies, and reconcile controlled substances. An antibiotic ointment lacked an open date, expired tubing was found in an emergency cart, and saline was improperly stored at a resident's bedside. Additionally, a controlled substance was not logged at the time of administration.
A facility failed to notify the hospice provider of a significant change in a resident's condition when the resident, diagnosed with end-stage Alzheimer's, was transferred to the hospital. Despite standard procedures requiring immediate notification of the hospice, there was no documentation of such communication. The DON confirmed the family was informed via voicemail, but the hospice was not notified, violating the facility's policy and hospice contract.
The facility failed to correct a repeated deficiency related to F761, involving improper labeling and storage of drugs. A nurse did not sign the narcotic log during medication administration, and an antibiotic eye ointment lacked proper labeling. Despite the facility's QAPI plan and monitoring efforts, the deficiency persisted.
Oxygen Therapy Not Provided at Ordered Rate
Penalty
Summary
Facility staff failed to provide oxygen therapy at the physician-ordered rate for Resident #104. On 02/02/2026 at 7:38 AM, the resident was observed in bed with eyes closed and a nasal cannula in place delivering oxygen at 3.5 liters per minute, although the physician order dated 01/26/2026 specified oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath or oxygen saturation less than 92%. Resident #104 was admitted with diagnoses including pneumonitis due to inhalation of food and vomit and had additional respiratory conditions requiring monitoring and treatment. The clinical record showed the resident was receiving oxygen therapy in the MDS, and the care plan identified altered respiratory status/difficulty breathing related to anxiety and pulmonary edema with interventions to administer oxygen and respiratory treatments as ordered. On 02/03/2026 at 11:13 AM and 02/04/2026 at 10:13 AM, the resident was observed seated in a wheelchair with no oxygen in use. Staff interviews confirmed that nursing staff were expected to review physician orders, complete a respiratory assessment, and administer oxygen and nebulizer treatments according to the physician's prescription.
Improper Storage of Medications and Topical Products
Penalty
Summary
Safe and secure storage of medications and biologicals was not maintained for five sampled residents when surveyors found ointments, lotions, creams, and pills left in resident rooms rather than stored in locked medication storage as described by facility staff and policy. During room observations on the 2nd floor North/South Unit, Resident #6 had a tube of ointment on the overbed table while in bed and later while out of the facility; Resident #31 had a tube of ointment on the bedside table; Resident #32 had a tube of ointment on the overbed table; and Resident #102 had a tube of ointment and a bingo pack of white round pills at the bedside. Resident #9 had several lotions and creams on the bedside table, and later several lotions and creams were observed in a wooden crate on the bedside table. The medical record reviews showed that these residents were admitted or readmitted with diagnoses including cerebral infarction, polyneuropathy, fracture of the right patella, and diverticulosis with bleeding. Their MDS assessments documented that Residents #6, #9, #31, #32, and #102 were cognitively intact, with Brief Interview of Mental Status scores ranging from 13 to 15. Functional status documentation showed varying levels of assistance needs, including supervision, dependence, or maximal assistance for personal hygiene and activities of daily living, with impairment affecting the lower extremities for several residents and both upper and lower extremities for one resident. Interviews with nursing and CNA staff showed a consistent understanding that prescribed creams and ointments were to be kept on the medication cart, while residents' personal lotions and creams were to be stored in resealable plastic bags in bedside drawers. Staff also stated that if such items were found in resident rooms, they were to be given to the nurse or stored in the bedside drawer. The facility's undated medication storage policy stated that medications must be stored to maintain product integrity and resident safety and in accordance with Florida requirements.
QAA Committee Failed to Address Repeated F761 Deficiency
Penalty
Summary
The facility’s QAA committee failed to demonstrate an effective plan of action was implemented to correct a repeated deficiency related to F761, Label/Store Drugs and Biologicals. During the recertification survey with exit dated 12/19/24, surveyors cited the facility because drugs and biologicals used in the facility were not stored and labeled properly. Record review showed this same deficiency had been cited during the recertification survey conducted from 12/16/24 through 12/19/24. The facility’s QAPI policy stated that quality improvement efforts were intended to guide the overall quality improvement program and that key issues would be addressed on an ongoing basis. Review of QAPI committee meeting sign-in sheets showed monthly meetings with attendance by the Administrator, Medical Director, DON, ADON, Infection Control Preventionist, Risk Manager, and other department leaders. During interview on 02/04/26, the DON stated the committee met monthly, reviewed prior month data, and had department heads report assigned tasks and new issues, with data entered into the QAPI log for discussion and recommended interventions.
Improper Storage of Cleaning Supplies in Resident Room
Penalty
Summary
The facility failed to ensure appropriate storage of personal cleaning supplies for one resident out of 18 sampled residents. During initial room screenings on the 2nd floor North/South Unit, dishwashing liquid soap and disinfectant spray were observed stored in Resident #101’s room on a shelf above the handwashing sink. The supplies were still present in the room during a later observation, even though the resident was out of the facility for an appointment at that time and a housekeeper was mopping the floor in the room. Resident #101’s clinical record showed admission to the facility with diagnoses of aftercare following joint replacement surgery and unilateral primary osteoarthritis of the left knee. The admission MDS documented a BIMS score of 15, indicating the resident was cognitively intact. Staff interviews stated that cleaning supplies such as dishwashing soap and disinfectant spray found in residents’ rooms should be removed from the room and given to nursing staff or the supervisor, and the RN supervisor stated that cleaning supplies are not allowed to be stored in residents’ rooms. The facility policy titled Storage Areas Environmental stated that cleaning supplies shall be stored in areas separate from food storage rooms and as instructed on product labels.
Resident Elopement Due to Inadequate Supervision and Failure to Identify Elopement Risk
Penalty
Summary
A deficiency occurred when a resident with multiple medical and psychiatric diagnoses, including dementia, major depressive disorder, and an indwelling urinary catheter, was able to leave the facility undetected. The resident, who was admitted recently and had expressed a desire to go home, exited the building by following a group of visitors through the front door. The facility's video footage confirmed that the resident left his room, used the elevator to reach the ground floor, and exited alongside visitors while talking on the phone. At the time, the receptionist was occupied assisting other guests, and the electronic door system was used to allow the group to leave, enabling the resident to exit without staff intervention. The facility's policies required identification and care planning for residents at risk of wandering or elopement, as well as regular checks and documentation for those with elopement risk. However, the resident was not identified as exit-seeking or at risk for elopement upon admission, and his care plan did not include specific interventions for wandering or elopement prevention. Staff interviews revealed that the resident had been agitated and expressed a desire to leave earlier in the evening, and his wife had communicated this to the assigned LPN. Despite this, the resident was not under increased supervision, and staff only became aware of his absence after his wife reported that he had called her from outside the facility. Following the discovery of the resident's absence, staff initiated a Code Silver alert and conducted a search of the building and surrounding area. The resident's daughter arrived at the facility shortly after, reporting that he had safely arrived home, which was several blocks away. The incident was documented in the facility's records, and interviews with staff confirmed the timeline and circumstances of the resident's elopement. The event demonstrated a failure to provide adequate supervision and to ensure the area was free from accident hazards, as required by facility policy and regulatory standards.
Expired Disinfectant Wipes Found on Two Floors
Penalty
Summary
The facility failed to implement proper infection control protocols regarding the use of disinfectant wipes on two out of three floors. During a facility tour, surveyors observed expired disinfectant wipes on the second and third floors, with one container on the second floor and two containers on the third floor having expired dates. Additionally, two containers had illegible expiration dates. The Minimum Data Set (MDS) Coordinator confirmed the expiration of the wipes and indicated that the Housekeeping Director would be notified to replace them. Interviews with the Housekeeping/Maintenance Director revealed that he was responsible for replacing the disinfectant wipes and checked them weekly. However, he admitted to refilling old containers with new wipes without updating the expiration dates, leading to confusion among staff. Certified Nursing Assistants (CNAs) on the second floor stated they checked expiration dates before using the wipes and reported expired wipes to maintenance. The Nursing Supervisor and the Facility's Infection Preventionist emphasized that staff should not use expired wipes and that Environmental Services personnel were responsible for replacing expired or finished Personal Protective Equipment (PPE). The facility's policy on infection prevention and control was reviewed, highlighting the need for coordination and oversight by an infection prevention specialist.
Deficiencies in Drug Labeling, Storage, and Controlled Substance Reconciliation
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, as well as the disposal of expired medical supplies. During an inspection, an antibiotic eye ointment prescribed for a resident was found without an open or expiration date on the medication cart. The staff member responsible for the cart could not provide the necessary information and deferred to a supervisor. Additionally, expired tubing was found in the emergency cart, which was acknowledged by the staff as being the first tubing used in an emergency, despite the supervisor's claim that the cart is checked daily. Another deficiency was observed when two bottles of saline were found on a resident's bedside, which is against the facility's policy. The staff member responsible for the resident's care admitted to not noticing the saline during morning rounds and explained that it was used for cleaning the resident's colostomy. The saline was subsequently discarded by the staff member. Furthermore, there was a failure to properly reconcile controlled substances. A resident who complained of knee pain was administered Tramadol, but the administration was not recorded in the controlled substance log at the time of administration. The staff member admitted to not signing the log immediately due to attending to the resident. The Director of Nursing confirmed that narcotics should be signed out at the time of administration, highlighting a lapse in protocol adherence.
Failure to Notify Hospice of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the hospice provider of a significant change in condition for a resident receiving hospice care. The resident, who had been diagnosed with end-stage Alzheimer's disease, was transferred to the hospital via emergency services. However, there was no documentation indicating that the hospice provider was informed of this transfer. The resident's care plan, which was revised shortly before the incident, emphasized the importance of comfort and palliative care, and the facility had a contractual obligation to notify the hospice of any significant changes in the resident's condition, including transfers to other facilities. Interviews and record reviews revealed that the nursing supervisor stated that it is standard procedure to notify the doctor, family, and hospice nurse immediately when a hospice resident is sent to the hospital. However, the hospice nurse did not recall being notified of the resident's hospital transfer. The Director of Nursing confirmed that the family was informed via voicemail, but the hospice was not notified as required. The facility's policy and hospice contract both mandated immediate communication with the hospice provider regarding significant changes in a resident's condition, which was not adhered to in this case.
Repeated Deficiency in Drug Labeling and Storage
Penalty
Summary
The facility failed to effectively implement corrective actions for a repeated deficiency related to F761, which involves the labeling and storage of drugs and biologicals. Specifically, a nurse did not sign the narcotic log at the time of medication administration, and an antibiotic eye ointment was not labeled with its expiration and opened date. This deficiency was previously cited during a recertification survey, where the facility was found to have failed in securing a controlled medication. The facility's Quality Assurance and Performance Improvement (QAPI) plan outlines procedures for monitoring performance and establishing improvement goals. However, despite these procedures, the facility did not demonstrate effective corrective actions for the identified deficiency. The QAPI committee, which includes various department heads and meets monthly, is responsible for addressing performance improvements. Despite audits and monitoring efforts, the deficiency related to drug labeling and storage persisted, indicating a lapse in the facility's adherence to its own policies and procedures.
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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 Miami
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coral Gables Nursing And Rehabilitation Center | 0.6 mi | ★★★★★ | 1 | 0 |
| West Gables Health Care Center | 1.1 mi | ★★★★★ | 3 | 0 |
| Floridean Health & Rehabilitation Center | 4.4 mi | ★★★★★ | 4 | 0 |
| Miami Springs Nursing And Rehabilitation Center | 4.5 mi | ★★★★★ | 0 | 0 |
| Riviera Health Resort | 4.5 mi | ★★★★★ | 1 | 0 |
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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.