Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Susanna Wesley Health Center during CMS and state inspections, most recent first.
Unsecured razor left within resident reach. A resident with dementia, anxiety, depression, and limited ADL independence was observed with a disposable razor left on the bedside nightstand and still accessible hours later. The resident’s record showed he required substantial/maximal staff assistance with personal hygiene, including shaving, and there was no order or care plan authorizing independent shaving or keeping razors in the room. Staff interviews confirmed razors were to be controlled by CNAs and disposed of in a sharps container after use.
QAA/QAPI committee failed to show an effective plan of action for a repeated F689 deficiency involving free of accident hazards/supervision/devices. Surveyors had cited the facility after a fire lighter was observed in a transparent bag next to a resident seated in the activities area with other residents present. Monthly QAA meetings were documented, and the DON stated the committee reviewed data, discussed department observations, and used root cause analysis to identify interventions, but the record did not show an effective plan was implemented to correct the repeated deficient practice.
A computer screen displaying residents' personal and medical information was left unattended and visible in a hallway, making the information easily accessible to unauthorized individuals. Staff interviews confirmed that the protocol required the computer screen to be locked when unattended, but this was not followed, resulting in a breach of confidentiality.
A resident with an indwelling urinary catheter was not accurately coded in the MDS, despite clinical records, physician orders, and care plans documenting catheter use. Staff confirmed the omission was an error, and the facility's policy requiring accurate assessments was not followed.
A resident with a gastrostomy tube had a care plan intervention for an abdominal binder, despite no physician order and no evidence of its use. Staff, including an LPN and CNA, confirmed the binder was never applied, and the MDS Coordinator stated its inclusion was an error that was missed during care plan review. The care plan was not updated to accurately reflect the resident's needs and current orders.
A resident who was not identified as a smoker was found with a fire lighter in a transparent bag while seated in the activities area with other residents. The lighter was not detected by staff during daily rounds, and the assigned CNA was unaware of its presence. The DON confirmed the resident was not allowed to have a lighter, indicating a lapse in supervision and failure to maintain an environment free from accident hazards.
Surveyors identified a repeated deficiency in the accuracy of MDS assessments, with the facility failing to properly code an indwelling urinary catheter for a resident. Despite monthly QAPI/QAA committee meetings and a policy emphasizing data-driven quality improvement, the issue persisted after being previously cited for similar inaccuracies affecting two residents.
Staff failed to follow infection prevention and control procedures, including leaving trash in a hallway and not changing gloves or performing hand hygiene during perineal and catheter care for a resident with a history of UTIs and an indwelling catheter. Observations and staff interviews confirmed lapses in maintaining a sanitary environment and proper care techniques.
A resident was charged $100.00 for someone to accompany him to medical appointments, contrary to the facility's policy. The resident's family had to pay in cash, and this practice was not documented in the facility's admission packet. Interviews revealed inconsistencies in staff awareness and adherence to the policy.
Unsecured razor left within resident reach
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards and failed to provide adequate supervision when Resident #23 was left with an unsecured disposable razor on the bedside nightstand for several hours. On 07/07/2026 at 10:35 AM, the resident was observed lying in bed watching television with a blue disposable shaving razor placed within reach on the nightstand. When asked about it, the resident said staff had provided the razor shortly before the surveyor arrived and stated he could shave independently, but he could not recall which staff member gave it to him. The same razor was still on the nightstand and readily accessible during a later observation at 2:10 PM that day. Resident #23’s record showed diagnoses including unspecified dementia, recurrent major depressive disorder, anxiety disorder, and muscle wasting of both upper arms. The quarterly MDS indicated a BIMS score of 13 out of 15, with no behaviors coded, and Section GG showed substantial/maximal staff assistance was required for personal hygiene, including shaving. The care plan identified risk for impaired skin integrity related to multiple medical conditions and included interventions to avoid mechanical trauma such as improper shaving. The resident also had an ADL care plan for assistance with personal hygiene, and task documentation from 06/09/2026 through 07/08/2026 showed he required assistance with personal hygiene on most days, with only one day documented as independent. Review of physician orders from 12/17/2025 through 07/08/2026 showed no order authorizing the resident to shave independently or keep razors in his room. Staff interviews confirmed that CNAs were responsible for shaving residents, that razors were to be obtained from the utility room, maintained by staff during use, and disposed of in a sharps container after the task was completed. Staff A, Staff B, and the DON all acknowledged that no sharp objects, including disposable razors, should be left unattended in resident rooms, and the DON confirmed there was no documentation supporting independent shaving or possession of razors by Resident #23.
QAA/QAPI Committee Failed to Show Effective Action on Repeated F689 Deficiency
Penalty
Summary
The facility's QAA/QAPI committee failed to demonstrate that an effective plan of action was implemented to correct a repeated deficiency related to F689, Free of Accident Hazards/Supervision/Devices. The facility had been cited for F689 on 6/12/2025 after surveyors observed a fire lighter in a transparent bag next to a resident who was seated in the activities area with other residents gathered around. The repeated deficient practice had the potential to affect any of the 119 residents in the facility at the time of the survey. Record review showed the facility's QAPI policy stated it was the facility's policy to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program focused on outcomes of care and quality of life. QAPI Committee Meeting sign-in sheets dated 04/15/2026, 05/20/2026, and 06/23/26 documented monthly QAA committee meetings with attendance by the Administrator, DON/Risk Manager, Medical Director, Infection Control Preventionist, Business Office Manager, Human Resources, Social Services Director, Rehab Director, Dietary Director, Dietitian, Activities Director, Housekeeping Director, Maintenance Director, MDS Coordinator, Admissions, Medical Records, Restorative, and Wound Care. During interview, the Administrator and DON stated the committee met monthly to review data and observations from each department and that departments proposed interventions and solutions for identified problems using root cause analysis within an ongoing QAPI process.
Unattended Computer Screen Exposes Resident Information
Penalty
Summary
A deficiency occurred when a computer screen displaying residents' personal and medical information was left unattended and visible in a third-floor hallway. This observation was made during a survey, where the information on the screen was easily accessible to unauthorized individuals. The facility had 118 residents at the time of the survey. Staff interviews confirmed that the protocol required the computer screen to be locked and not merely minimized when unattended, as minimizing the screen could allow the information to be easily accessed if the cart was moved. Further review of the facility's confidentiality policy indicated that all resident records, regardless of format, must be kept secure and confidential, and that information should not be left viewable by unauthorized persons. The Director of Nursing confirmed that staff had been instructed to lock the computer screen when leaving the medication cart. However, the observed practice did not align with the facility's policy, resulting in a failure to protect residents' confidential information.
Failure to Accurately Code MDS for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident who had an indwelling urinary catheter in place since admission. Observations on two separate occasions confirmed the presence of the catheter, and clinical records, including physician orders and care plans, documented its use for obstructive uropathy. Despite this, the MDS assessment did not indicate the presence of an indwelling urinary catheter, as the relevant section was marked 'None of the above.' Interviews with staff, including the MDS Coordinator, confirmed that the omission was an error and that the catheter should have been coded in the MDS. The facility's policy requires that all resident assessments accurately reflect the resident's status at the time of assessment, but this was not followed in this instance. The deficiency was identified through observations, record reviews, and staff interviews.
Failure to Revise Care Plan to Remove Unordered Abdominal Binder Intervention
Penalty
Summary
The facility failed to revise the care plan for a resident with a gastrostomy tube, resulting in the continued inclusion of an intervention for an abdominal binder despite the absence of a physician's order for its use. The resident, who was admitted with diagnoses including dysphagia following cerebral infarction and required tube feeding, had a care plan intervention stating that an abdominal binder should be used at all times, with removal only during care for skin inspection. However, review of the physician's orders confirmed there was no order for an abdominal binder, and multiple staff members, including an LPN and a CNA regularly assigned to the resident, reported never having seen the binder in use. The MDS Coordinator acknowledged that the abdominal binder intervention was mistakenly included in the care plan upon the resident's admission and was overlooked during the most recent quarterly review. The facility's policy requires that care plans be comprehensive, person-centered, and consistent with the resident's assessment and professional standards, but the care plan was not updated to reflect the resident's actual needs and physician orders. This resulted in a care plan intervention that was not implemented or medically indicated.
Failure to Prevent Accident Hazard Due to Resident Possession of Fire Lighter
Penalty
Summary
A fire lighter was observed in a transparent bag next to a resident who was seated in the activities room among other residents. The resident, who is cognitively intact and requires partial to moderate assistance for eating, was not identified as a smoker in their clinical records or Minimum Data Set (MDS) assessment. When questioned, the resident declined to explain the presence of the lighter. The assigned CNA was unaware of the lighter and did not know if the resident smoked. The Registered Nurse Manager was notified and immediately removed the lighter, confirming that the resident was not permitted to have it and was not a smoker. The facility's policy requires the environment to be as free of accident hazards as possible and mandates adequate supervision to prevent accidents, including identifying and removing hazards. Despite daily rounds intended to identify hazardous materials, the lighter was not detected until observed by the surveyor. The Director of Nursing noted that the resident was previously homeless and resistant to staff handling his belongings, but could not explain how the lighter was acquired. This incident demonstrates a failure to provide adequate supervision and to ensure the environment was free from accident hazards as required by facility policy.
Repeated Deficiency in MDS Assessment Accuracy
Penalty
Summary
The facility failed to implement effective action plans to correct previously identified quality deficiencies related to the accuracy of Minimum Data Set (MDS) assessments. During a recertification survey, surveyors found that the facility inaccurately coded the MDS for two out of four residents reviewed, specifically failing to code an indwelling urinary catheter under section H for one resident. Despite the existence of a Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) committee that meets monthly and includes all required interdisciplinary team members, the same deficiency was cited again during a subsequent survey, indicating that the issue of inaccurate MDS coding persisted. The facility's policy states that it maintains a comprehensive, data-driven QAPI program focused on care outcomes and quality of life, but the repeated deficiency demonstrates that the identified problem with MDS coding was not effectively addressed.
Failure to Implement Infection Control Practices During Perineal and Catheter Care
Penalty
Summary
Facility staff failed to implement infection prevention and control policies and procedures, resulting in unsanitary conditions and improper perineal and catheter care. During an observational tour, two clear plastic bags containing trash were found in the third-floor hallway next to a resident's room, contrary to facility protocol requiring immediate disposal in designated bins within the soiled utility room. Staff interviews confirmed that trash and soiled supplies should not be left in hallways, indicating a lapse in maintaining a sanitary environment. Additionally, a Certified Nursing Assistant (CNA) was observed performing perineal care for a resident with an indwelling urinary catheter and a history of recurrent UTIs. The CNA did not change gloves or perform hand hygiene when transitioning from contaminated to clean areas and did not change the water in the basin between cleaning steps, deviating from standard infection control practices. The resident was dependent on staff for all activities of daily living and had a care plan identifying elevated UTI risk due to the catheter. Staff interviews revealed inconsistent understanding of proper infection control protocols, and the Infection Control Preventionist acknowledged the concerns, confirming that staff are required to change gloves and wash hands between perineal and catheter care.
Failure to Provide Medically Needed Social Services
Penalty
Summary
The facility failed to ensure medically needed social services were provided for a resident, who was charged $100.00 for someone to accompany him to medical appointments. The facility's policy stated that a member of the nursing staff or social services would accompany the resident if family was unavailable, but this was not followed. Instead, the resident's family was required to pay $100.00 in cash for someone from the community to accompany the resident, which was not documented in the facility's admission packet or policy. The resident in question had multiple medical conditions, including surgical aftercare, dysphagia, heart disease, diabetes, chronic kidney disease, peripheral vascular disease, parkinsonism, depression, and shortness of breath. Despite these conditions, the facility did not provide the necessary social services support for his medical appointments. The resident's daughter confirmed that she had to pay $100.00 each time for transportation and accompaniment, and this payment was documented in letters signed by a family friend and the unit secretary. Interviews with facility staff, including the third-floor secretary, social services director, and DON, revealed inconsistencies in the facility's practices. The third-floor secretary and social services director acknowledged the $100.00 charge, while the DON and administrator were unaware of this practice. The administrator stated that the practice of collecting money for accompaniment would stop immediately, indicating a lack of oversight and communication within the facility's management team.
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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) |
|---|---|---|---|---|
| Palmetto Care Center And Rehab | 1.3 mi | ★★★★★ | 8 | 0 |
| Waterford Nursing And Rehabilitation Center | 1.3 mi | ★★★★★ | 8 | 0 |
| Terrace Of Hialeah, The | 2.4 mi | ★★★★★ | 7 | 0 |
| Miami Springs Nursing And Rehabilitation Center | 4 mi | ★★★★★ | 0 | 0 |
| Hialeah Shores Nursing And Rehab Center | 4.2 mi | ★★★★★ | 0 | 0 |
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