Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Terrace Of Hialeah, The during CMS and state inspections, most recent first.
Oxygen therapy was not delivered as ordered for five residents. Observations found NC oxygen concentrators set at rates above or below the prescribed lpm for residents with COPD, respiratory failure, asthma, CHF, and other respiratory conditions. RN interviews confirmed staff were responsible for verifying the ordered flow rate and monitoring residents on oxygen throughout the shift.
QAPI Program Not Effective With Repeated Deficiencies: The facility was cited again for repeated deficient practices involving F0584, F0645, and F0695 after having prior citations for the same areas. The Administrator stated the QAA committee met monthly and used audits, rounds, staff reports, and other monitoring methods, but survey findings still showed recurring issues with PASARR documentation, prescribed respiratory care, and housekeeping/maintenance.
Housekeeping and maintenance services failed to keep resident areas sanitary, clean, and homelike. Surveyors observed stained toilet seats, trash on bathroom floors, a ripped bedside chair cushion, and hallway walls with scruff marks, black spots, stains, scrapes, dents, and dings. The DOR of Housekeeping said staff were responsible for cleaning resident rooms, bathrooms, and hallways, while CNAs were responsible for maintaining room cleanliness after the initial cleaning; the DOR of Maintenance and the Administrator acknowledged that old chairs in disrepair were being replaced over time.
Inaccurate MDS Coding for Oxygen Therapy: A resident with COPD was observed multiple times in bed with O2 via NC, and the physician’s orders included continuous O2 at 3 LPM. Although the care plan noted dependence on continuous oxygen, the quarterly MDS did not code oxygen therapy in Section O, and the MDS coordinator acknowledged the omission.
PASARR Missing Mental Health Diagnoses: The facility failed to update a resident’s PASARR to include SMI diagnoses after the resident was diagnosed with depression, anxiety, and bipolar disorder and began receiving treatment. The resident also had Parkinson’s disease and moderate to severe cognitive impairment, and the record showed use of antidepressant and anti-anxiety meds, including clonazepam, while both the hospital and facility PASARR forms omitted the mental health diagnoses.
The facility failed to provide a clean and sanitary environment, with observations of garbage on floors, torn bed linens, and a hole in a wall. Interviews with staff indicated awareness of these issues, but the facility's cleaning policy was not followed, affecting multiple residents.
A resident was found in a bed positioned in a way that restricted their ability to get out without assistance, effectively acting as a physical restraint. The resident, who was moderately cognitively impaired and dependent on care, had no documented need for restraints. The facility's policy prohibits the use of restraints for convenience, yet the setup was observed on multiple occasions.
The facility failed to complete PASRR Level I screenings for four residents, leading to a lack of proper identification of serious mental illness or intellectual disabilities. Residents with histories of mental illness, such as bipolar disorder, anxiety, and depression, were not properly evaluated, and their PASRR forms were incomplete or incorrectly filled. This oversight affected the care planning process and had the potential to impact all residents in the facility.
A deficiency was identified when a bundle of shaving razors was found in a resident's drawer, posing a safety risk. The resident, with severe cognitive impairment and Alzheimer's, was at risk for falls and required a clutter-free environment. Staff acknowledged the error, noting razors should not be in resident rooms and should be disposed of in sharps containers.
A resident with cognitive impairment and respiratory issues was observed with a CPAP machine improperly positioned on her forehead, despite it being turned on. The resident's care plan required continuous oxygen therapy, but a nurse admitted to only checking the machine at the start of her shift. The resident's medical history includes heart failure and COPD, necessitating careful monitoring of oxygen therapy.
The facility failed to follow pharmaceutical procedures during medication administration for two residents, resulting in missed doses of Simethicone and Amlodipine. Additionally, discrepancies in narcotic counts for Clonazepam and Tramadol were found due to improper signing and reconciliation of controlled substances.
A facility failed to maintain a medication error rate below five percent, with two instances of medication omissions observed. One resident did not receive Simethicone 125 mg due to unavailability in the prescribed form, and another resident did not initially receive Amlodipine Besylate 10 mg due to a nurse's oversight. Both residents had specific medical conditions requiring these medications.
The facility failed to properly store medications for two residents, as vitamins, nasal spray, and rubbing alcohol were found on their side tables. Nurses removed the items and informed the residents that medications should not be kept at the bedside without notifying the nurse. The Director of Nursing confirmed that medications require a doctor's order and nursing assessment for in-room storage.
The facility's QAA Committee failed to implement effective corrective actions for repeated deficiencies in PASRR Screening, Pharmacy Services, and safety measures. Despite a structured QAPI Program and regular meetings, the facility could not demonstrate effective action, impacting all 231 residents.
Oxygen Therapy Delivered at Incorrect Flow Rates
Penalty
Summary
The facility failed to ensure oxygen therapy was delivered as prescribed for five residents receiving oxygen via nasal cannula. During observations, each of the five residents was found with oxygen running at a rate that did not match the physician’s order. Resident 9 was observed with oxygen running at 3.5 lpm and later at 3 lpm, while the order was for 3 lpm continuously. Resident 90 was observed with oxygen running at 3 lpm and later at 2 lpm, while the order was for 2 lpm continuously. Resident 214 was observed with oxygen running at 2.5 lpm, while the order was for 3 lpm continuously. Resident 240 was observed with oxygen running at 3 lpm and later at 2 lpm, while the order was for 2 lpm continuously. Resident 258 was observed with oxygen running at 2.5 lpm and later at 2 lpm, while the order was for 2 lpm continuously. The records for these residents showed diagnoses including COPD, respiratory failure with hypoxia, asthma, heart failure, obesity with alveolar hypoventilation, and other conditions associated with respiratory status. The MDS and care plans documented that these residents were dependent for care and had respiratory-related needs, including continuous oxygen therapy and interventions to administer oxygen as ordered. Interviews with two RNs on the unit indicated they were responsible for checking oxygen orders, verifying concentrator settings, and monitoring residents on oxygen therapy at the start of the shift and at least every two hours. One RN acknowledged that other staff could accidentally change the concentrator flow rate, but stated it remained the assigned nurse’s responsibility to ensure oxygen was running at the correct rate at all times. The facility policy on oxygen concentrators stated that staff responsible for their use and care receive training on oxygen safety and device functionality, and that oxygen is administered under physician orders.
QAPI Program Not Effective With Repeated Deficiencies
Penalty
Summary
Failure to develop and implement an effective QAPI program was identified based on repeated deficient practices cited during the current survey and the facility’s prior survey history. The facility had previously been cited for F0584, F0645, F0695, and F0867 during the recertification survey with an exit date of 06/26/2024, and the current survey with an exit date of 12/05/2025 again identified repeated deficient practices for F0584 Safe/Clean/Comfortable/Homelike Environment, F0645 PASARR, and F0695 Respiratory/Tracheostomy Care and Suctioning. The facility had 235 residents at the time of the survey. During interview, the Administrator stated the QAA committee met monthly and included multiple disciplines, and described that concerns were raised through morning meetings, audits, staff reporting, department head rounds, and other monitoring activities. The facility’s policy stated that QAPI is a coordinated, systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes. Despite this, the survey findings showed repeated citations for the same deficient practices across surveys, including incomplete PASARR documentation, failure to ensure prescribed respiratory care, and issues related to housekeeping and maintenance.
Housekeeping and Maintenance Failures in Resident Areas
Penalty
Summary
The facility failed to provide housekeeping and maintenance services to ensure a sanitary, clean, and homelike environment. During observation of the [NAME] Unit, surveyors found red and green colored stains on the toilet seat in a resident bathroom in room 124, soiled trash on the floor in resident bathrooms in rooms 122 and 126, a ripped bedside chair cushion in a resident room, and hallway walls from rooms 101-116 with scruff marks, black spots, stains, scrapes, dents, and dings. During interview, the Director of Housekeeping stated there were seven housekeeping staff working 5:00 AM to 1:30 PM, with one person in the morning and one in the afternoon assigned to remove garbage from soiled utility rooms. The morning housekeeping staff were responsible for cleaning resident rooms, bathrooms, and hallways, and after the initial cleaning, CNAs were responsible for maintaining room cleanliness. The Director of Housekeeping also stated the facility was in the process of waxing the walls when the survey began and had stopped, and the Director of Maintenance and Administrator acknowledged that old chairs in disrepair were being replaced over time. The facility policy titled Infection Control-environmental Services stated the purpose was to control the spread of infection by maintaining a thoroughly clean and safe environment.
Inaccurate MDS Coding for Oxygen Therapy
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident, who was reviewed for resident assessments. The resident had a diagnosis of COPD and was observed on several occasions in bed with oxygen running via nasal cannula. The physician’s orders for December 2025 included oxygen at 3 liters per minute via nasal cannula continuously every shift, and the resident’s care plan documented that the resident depended on continuous oxygen and included interventions to administer oxygen as ordered. Review of the resident’s quarterly MDS dated [DATE] showed that Section C documented the Brief Interview for Mental Status score as unable to be determined, and Section O documented hospice care, but oxygen therapy was not coded. During interview, the MDS Coordinator stated that staff review the resident physically, physician orders, nurses’ notes, and medical documents to complete assessments, and acknowledged that the resident had an order for continuous oxygen but oxygen therapy was not coded in Section O on the most recent quarterly assessment.
PASARR Missing Mental Health Diagnoses
Penalty
Summary
The facility failed to complete and update a PASARR for one resident by not including the resident’s serious mental illness diagnoses on the PASARR form. The resident was initially admitted and later re-entered the facility with medical diagnoses that included Parkinson’s disease without dyskinesia, mood disorder due to a known physiological condition, bipolar disorder, generalized anxiety disorder, and major depressive disorder, single episode, unspecified. Record review showed a Significant Change - No PPS MDS with no mention of PASARR in Section A, a BIMS score of 6 in Section C indicating moderate to severe cognitive impairment, and Section I listing anxiety, depression, and bipolar disorder. Section N showed no antipsychotic medications, but antidepressant and anti-anxiety medications were being given. The resident’s care plan included use of anti-anxiety medication for anxiety disorder and antidepressant medication for depression and insomnia, with monitoring for adverse reactions such as drowsiness, confusion, impaired judgment, hostility, hallucinations, oversedation, and suicidal thoughts. A physician order showed clonazepam 1 mg twice daily for anxiety. The admission PASARR from the hospital and the facility PASARR did not document the resident’s mental health diagnoses of depression, anxiety, and bipolar disorder after those diagnoses became effective and treatment began. The Social Services Director stated that neither PASARR contained the diagnoses listed in the medical record and acknowledged that the PASARR should have been updated when the diagnoses became effective.
Deficiency in Maintaining a Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by multiple observations of garbage on the floors in several residents' rooms, bed linens with multiple holes, a large hole in the wall near an electrical outlet, and dirty walls in a resident's room. These observations were made over two days, with specific times and room numbers noted. The facility housed 231 residents at the time of the survey, indicating a widespread issue affecting multiple areas within the facility. Interviews with facility staff revealed that the Director of Nursing and Corporate Nurse were aware of the environmental concerns, and the Director of Maintenance had recently addressed the hole in the wall. The Director of Housekeeping outlined the housekeeping staff's schedule, which included cleaning offices and common areas before moving to residents' rooms, suggesting a possible delay in addressing cleanliness in residents' personal spaces. The facility's policy on maintaining clean floors was not adhered to, as evidenced by the observations of garbage and unclean conditions.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as observed by surveyors. The resident's bed was positioned with the foot elevated and the head flat, with an overbed table placed at the side of the bed, effectively preventing the resident from getting out of bed without assistance. This setup was observed on multiple occasions, indicating a consistent practice rather than an isolated incident. The resident, who was moderately cognitively impaired and dependent on care, had no documented need for restraints or alarms in their medical records. The resident's medical records showed a history of depression, with prescribed medications including Mirtazapine and Trazodone. The care plan included interventions related to the administration and monitoring of these medications, but there was no indication of behaviors that would necessitate the use of physical restraints. The facility's policy on restraints emphasized the prohibition of restraints for discipline or convenience, and the need for medical symptoms to warrant their use, which was not evident in this case.
Incomplete PASRR Screenings for Residents
Penalty
Summary
The facility failed to ensure the completion of the Preadmission Screening and Resident Review (PASRR) Level I for four residents, which is a requirement to identify individuals with serious mental illness (SMI) or intellectual disabilities (ID) before admission. This deficiency was identified during a survey and had the potential to affect all 231 residents in the facility. The PASRR Level I forms for the residents in question were either incomplete or incorrectly filled, leading to a lack of proper identification and evaluation of their mental health needs. Resident #60 was observed to be non-responsive and had a history of mental illness, including bipolar disorder and anxiety. Despite these diagnoses, the PASRR Level I form did not indicate any serious mental illness, and sections of the form were left incomplete. Interviews with staff revealed that the resident required medication to manage agitation and anxiety, yet the necessary screening to determine appropriate care was not conducted. Similarly, Resident #3 had a history of advanced dementia, depression, and psychosis, but the PASRR Level I form did not reflect these conditions, and no Level II evaluation was deemed necessary. The resident was on multiple psychotropic medications, indicating a need for careful monitoring and evaluation. Resident #112 and Resident #127 also had incomplete PASRR screenings despite having diagnoses of anxiety, depression, and bipolar disorder. The facility's policy required PASRR screenings for all admissions, but these were not properly executed, leading to a significant oversight in the care planning process.
Safety Lapse: Razors Found in Resident's Room
Penalty
Summary
A deficiency was identified in the facility's safety protocols when a bundle of shaving razors was found in the drawer next to a resident's bed. The resident, who has Alzheimer's disease with late onset and a severe cognitive impairment as indicated by a BIMS score of 3, was observed lying in bed with the razors within reach. The resident's care plan highlighted a risk for falls due to unawareness of safety needs, with interventions to maintain an environment free of clutter. Despite these precautions, the razors were accessible, posing a potential hazard. Staff G, an RN, acknowledged the safety risk upon notification by the surveyor and removed the razors, indicating that they should not have been left in the resident's room. Staff L, a CNA, confirmed that razors are not allowed in residents' rooms and should be disposed of in a sharps container after use. The facility's policy on hazardous areas, revised in July 2017, mandates that sharp objects should not be accessible to vulnerable residents. However, the presence of the razors in the resident's drawer suggests a lapse in adherence to this policy.
Failure to Ensure Proper Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure that a resident received oxygen therapy as prescribed. During multiple observations, the resident was found with the CPAP machine positioned on her forehead, despite it being turned on and running. The resident was also observed with oxygen running via nasal cannula at 2 liters per minute, with no distress noted. A registered nurse acknowledged that the resident often removes the CPAP machine herself and admitted to checking the machine only at the beginning of her shift. The nurse also mentioned that she works part-time and in different areas daily, which may have contributed to the oversight. The resident, who is cognitively impaired and dependent on care, has a history of acute and chronic heart failure, chronic obstructive pulmonary disease, and acute respiratory failure. The physician's orders specified the use of a CPAP machine at bedtime with continuous oxygen at 2 liters per minute. The resident's care plan included administering oxygen as ordered, monitoring oxygen saturation, and assessing respiratory status. Despite these orders, the facility's failure to ensure the proper use of the CPAP machine and consistent monitoring of the resident's oxygen therapy led to the deficiency.
Medication Administration and Narcotic Count Deficiencies
Penalty
Summary
The facility failed to ensure proper pharmaceutical procedures during medication administration for two residents. During an observation, a registered nurse was unable to administer Simethicone 125 mg in capsule form to a resident due to its unavailability on the medication cart. The nurse contacted central supply, which confirmed the medication was only available in tablet form, not capsules as prescribed. The resident, who was moderately cognitively impaired, had a physician's order for the medication to be given every six hours for surgical aftercare following digestive system surgery. In another instance, a registered nurse failed to administer Amlodipine Besylate 10 mg to a resident with hypertensive heart disease and heart failure. The nurse initially documented that all medications were given, but upon review, realized the Amlodipine was omitted. The nurse then administered the missed medication after consulting the facility policy. The resident was cognitively intact, with specific orders to hold the medication if certain blood pressure or pulse conditions were met. Additionally, the facility did not maintain accurate narcotic counts for two residents. A discrepancy was found in the narcotic count for Clonazepam and Tramadol, with the number of tablets not matching the records. The issue arose from a failure to sign out medications properly and reconcile counts at shift changes. The facility's policy requires nurses to count controlled substances with a partner and verify the accuracy of log sheets, which was not adhered to in these cases.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two medication omissions during administration observations. During an observation, a registered nurse (Staff A) was unable to administer Simethicone 125 mg in capsule form to a resident because it was unavailable on the medication cart. The central supply only had the medication in tablet form, which was not as prescribed. The resident had a cognitive impairment and was receiving aftercare following digestive system surgery. The nurse intended to contact the resident's doctor for new orders. In another instance, a registered nurse (Staff B) failed to administer Amlodipine Besylate 10 mg to a resident with hypertensive heart disease and heart failure. The nurse initially documented that all medications were given, but upon review, realized the Amlodipine was omitted. The nurse then administered the missed medication after consulting the facility policy. The resident was cognitively intact, and the medication was to be held under specific blood pressure and pulse conditions.
Medication Storage Deficiency
Penalty
Summary
The facility failed to properly store medications for two residents, leading to a deficiency in medication storage compliance. During observations, a bottle of vitamins was found on the side table next to one resident, who was awake and alert in bed. The registered nurse, upon being notified by the surveyor, removed the bottle and informed the resident that medications are not allowed at the bedside without notifying the nurse. The resident acknowledged this information. The nurse stated that she did not observe the medication during her initial rounds and would notify the physician. In another instance, a nasal spray and rubbing alcohol were found on the side table of a second resident. The registered nurse, after being informed by the surveyor, removed these items and explained to the resident that medications should not be kept at the bedside without prior notification to the nurse. The resident agreed to this instruction. The nurse also mentioned that she did not see these items during her initial rounds and would inform the physician. The Director of Nursing confirmed that residents are not allowed to keep medications in their rooms without a doctor's order and assessment by the nursing staff.
Repeated Deficiencies in Quality Assurance Implementation
Penalty
Summary
The facility's Quality Assurance and Assessment Committee failed to effectively implement plans of action to correct identified quality deficiencies in several areas, including PASRR Screening for Mental Diagnosis and Intellectual Disability, Pharmacy Services and Procedures, and ensuring a safe environment free of accidents and hazards. These deficiencies were observed during a survey and were noted to be repeated issues that had been cited earlier in 2023. The deficiencies have the potential to impact all 231 residents residing in the facility at the time of the survey. The facility's Quality Assurance Performance Improvement (QAPI) Program, which was revised in November 2023, outlines a structured approach to quality assessment and improvement. However, despite having a QAA Committee that meets monthly and includes a comprehensive interdisciplinary team, the facility was unable to demonstrate that effective corrective actions were implemented to address the repeated deficiencies. The committee's role is to identify issues, track trends, and implement interventions, but the survey findings indicate a lack of effective action in these areas.
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What surveyors actually found near you
We read the 291 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.
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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) |
|---|---|---|---|---|
| Miami Springs Nursing And Rehabilitation Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Hialeah Shores Nursing And Rehab Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Susanna Wesley Health Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Waterford Nursing And Rehabilitation Center | 3.2 mi | ★★★★★ | 8 | 0 |
| Palmetto Care Center And Rehab | 3.7 mi | ★★★★★ | 8 | 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.