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 The Lilac At Silver Palms during CMS and state inspections, most recent first.
Improper Storage of Medications and Expired Drugs: Surveyors found expired IV supplies, saline, sterile water, Lansoprazole, and insulin in medication storage areas, along with medications and ointments left at bedside or in resident rooms without orders for several residents. Staff and the DON acknowledged that medications were not to be kept in resident rooms or at the bedside unless ordered, and that expired items were not to remain in carts or medication rooms.
Visible Cholecystostomy Drainage Bag During Therapy: A resident’s cholecystostomy drainage collection bag was observed visible and not covered in a privacy bag while the resident self-propelled in a wheelchair, ambulated with PT and an OTA, and sat in the therapy room with other residents. The resident had no cognitive impairment per MDS and required assistance with several ADLs; staff and the DON stated the bag was to be kept in a privacy covering to provide dignity.
Failure to protect resident information occurred when an RN left paperwork with residents' personal medical information unattended on top of a med cart and later left a computer screen open with resident information visible on the 2nd-floor unit. An LPN closed the screen after noticing it, and the DON stated staff are to close computer screens and turn paperwork over to keep resident information private.
Expired insulin was found in a med cart and had been administered to a resident with DM and severe cognitive impairment. An LPN confirmed the insulin pen was expired, yet the eMAR showed it had been given the prior day. The resident had orders for Admelog insulin twice daily, and the facility’s policy stated expired medications were not to be kept in carts or administered.
Accident hazards were found in resident areas when a razor was left in one resident’s room, a heating pad was observed in another resident’s room, a sharps container was filled to capacity, and an interior-lock door to a hallway with enteral and medical materials was left unlocked. Staff stated razors were not allowed in rooms, heating pads were not permitted due to burn/skin injury risk, sharps containers should be changed at 3/4 full, and the door should remain locked for resident safety.
Two residents with indwelling urinary catheters were observed with tubing positioned in a way that prevented urine from flowing freely. One resident’s tubing was looped with urine in the line and very little urine in the drainage bag, and another resident’s tubing extended through pants and was secured upward on a wheelchair. Records showed both residents had catheter-related orders and care plans directing staff to keep tubing below bladder level and free of kinks; interviews with the DON and IP confirmed tubing should remain straight and unkinked to prevent backflow and UTI.
Unlabeled resident food was found in the nourishment refrigerator on the Second Floor North Wing. An LPN opened a lunch bag that contained several food items and stated it belonged to a resident and should have been labeled and dated, and the DON confirmed resident food items in the refrigerator and freezer should be labeled and dated.
A resident receiving hospice care had no hospice nursing notes kept in the hospice folder, despite documented hospice visits and orders for hospice services. The resident had palliative care and HF diagnoses, moderate cognitive impairment, and a care plan for hospice visits. The LPN said hospice visits were checked by the sign-in book but the notes had not been received, and the DON stated hospice staff were expected to sign, send notes, and give report to floor nurses.
QAPI Program Failed to Address Repeated Deficiencies: The facility failed to show effective plans of action were implemented to identify repeated deficient practices in F880 Infection Prevention & Control, F689 Accident hazards/Supervision/Devices, and F761 Medication Storage. The same areas had been cited in a prior survey, while monthly QAA/QAPI meetings were held with the Administrator, DON, MD, and other dept heads; the Administrator stated QAPI is used to review interventions, evaluate and revise them as needed, and that some improvement plans remain ongoing.
Improper Storage of Respiratory and Enteral Equipment: An uncovered incentive spirometer was observed at one resident’s bedside, and an enteral syringe dated two days earlier was observed at another resident’s bedside on consecutive days. Staff stated respiratory supplies should be stored in dated plastic bags and enteral syringes should be changed every night shift, while the DON stated enteral syringes are not to be used more than 24 hours for infection control.
A facility failed to develop a fall care plan for a resident with a history of falls and severe cognitive impairment. Additionally, staff did not implement Enhanced Barrier Precautions for two residents with wounds, as they failed to wear required PPE during care. These deficiencies highlight lapses in care planning and infection control protocols.
The facility failed to adhere to infection control standards as three Soiled Utility Rooms were found unlocked during a survey. The RN Infection Control Preventionist confirmed the rooms were left unlocked during the day. An LPN Supervisor stated that the rooms should remain locked, with access controlled by nursing staff, highlighting a lapse in the facility's infection prevention policy.
A resident with Parkinson's and diabetes was observed with razors on their nightstand, contrary to facility policy requiring staff to store razors. Despite the resident's cognitive intactness and preference to shave independently, the facility's failure to adhere to its policy on razor storage posed an accident hazard.
A resident with respiratory disorders and cognitive impairment did not receive oxygen therapy as prescribed, with observations showing oxygen administered at 2 LPM instead of the ordered 3 LPM. This discrepancy was confirmed by a nurse, highlighting a failure to adhere to the facility's oxygen administration policy.
The facility failed to properly rotate dietary medication supplements, leading to two expired Vanilla Nutritional Drinks being found in the medication storage room. These supplements are used for residents during medication administration. Despite daily checks by nurses and additional checks by the central supply clerk and nursing supervisors, the expired items were not removed. There were 98 residents in the facility at the time.
Improper Storage of Medications and Expired Drugs
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional principles in two medication rooms and in resident areas. Surveyors found expired saline and sterile water on the second-floor treatment cart, expired IV start kits and alcohol pads in the first-floor medication room, expired liquid Lansoprazole for Resident #4 in the second-floor medication room, and an expired Admelog insulin pen for Resident #68 in the first-floor medication cart. The report also noted that the insulin pen remained in the cart and was administered on 2/17/2026 even though the expiration date had passed. Surveyors also observed medications and ointments left in resident rooms and at bedside locations. Resident #31 had A&D ointment on top of the dresser, Resident #108 had zinc oxide ointment on the bedside dresser, Resident #15 had zinc oxide and A&D ointments on the bedside table, Resident #60 had mupirocin ointment on the nightstand, Resident #5 had eye drops at the bedside, Resident #76 had a box of medication visible in an open drawer, and Resident #7 had ciclopirox topical solution on a shelf in the room during multiple observations. Review of the medication orders showed that Residents #15, #31, #108, #60, and #5 did not have orders for the observed ointments or eye drops, while Resident #76 did have an order for simethicone. Interviews confirmed that staff understood medications were not to be kept in resident rooms or at the bedside unless ordered, and that expired items were not to remain in medication rooms or carts. The DON stated ointments such as A&D and zinc oxide should only be kept in a resident's room with a physician's order and should be stored securely, and staff stated medications were to be kept in locked carts rather than resident rooms. The pharmacist consultant stated opened insulin expires after 28 days, and the facility policy required medications to be stored according to manufacturer recommendations with proper security and sanitation.
Visible Cholecystostomy Drainage Bag During Therapy
Penalty
Summary
The facility failed to honor one resident’s right to a dignified existence when the resident’s cholecystostomy drainage collection bag was observed visible and not inside a privacy bag during therapy-related activities. The resident was seen self-propelling in a wheelchair in the hallway toward the therapy room with the drainage bag visible, and was later observed being assisted with ambulation by the PT and an occupational therapy assistant while the bag remained visible. The resident was then seated in the therapy room among other residents with the cholecystostomy drainage bag still visible. The resident had been admitted and readmitted to the facility and had diagnoses including fusion of the lumbar spine. The resident’s MDS indicated a BIMS score of 14 with no cognitive impairment, dependence for toileting hygiene, substantial/maximal assistance for showering and bathing, partial/moderate assistance for dressing, and an indwelling catheter. The care plan included cholecystostomy care with observation for flush/drainage and signs or symptoms of infection, and the physician order directed observation of the cholecystostomy drainage catheter underneath the right breast for signs and symptoms of infection. Staff interviews confirmed awareness that the drainage bag was to be kept in a privacy covering to provide dignity, and the facility policy stated residents have the right to be treated with dignity and respect.
Failure to Protect Resident Information
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential when staff left paperwork containing residents' personal medical information unattended on top of a medication cart on the second-floor south unit. During observation, the paperwork was visible on the cart, and when the RN was made aware of the concern, she stated that resident information is kept private by closing computer screens and shredding documents, and that the paperwork should not have been on top of the cart and should have been shredded. The facility also failed to protect resident information when an RN left the 2nd floor medication cart in the hallway with the computer screen open and residents' information visible on the screen. Another LPN observed the open screen and closed it after being asked to help a resident. The DON stated that staff are to close computer screens and turn paperwork over to keep resident information private. The facility policy dated 1/2026 stated that medical records are to be maintained in accordance with State and Federal regulations and that clinical record information will be safely guarded against loss, destruction, or unauthorized use.
Expired Insulin Administered to Resident
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for one resident receiving insulin injections. During a medication cart inspection on the first floor, an insulin pen labeled for Resident #68 was found in the medication cart with an open date of 01/15/26 and an expiration date of 2/13/26. Staff E, an LPN, stated that the pen was expired. Review of the resident’s eMAR showed that the Admelog SoloStar insulin had been administered on 02/17/2026 at 5:36 PM by Staff E, LPN. Resident #68 was admitted with diabetes mellitus and had severe cognitive impairment, a Brief Interview of Mental Status score of 3, and orders for hypoglycemic medications including insulin. The care plan included accu checks and sliding scale insulin as ordered, and the physician order sheet showed an order for Admelog SoloStar 100 units/mL to be injected subcutaneously twice daily for type 2 DM. The DON stated that pharmacy staff checked medication carts every two weeks and removed expired medications, and that no expired medications were to be kept in medication rooms or carts or administered to residents. The pharmacist consultant stated that opened Admelog insulin pens expire after 28 days.
Accident Hazards Not Controlled in Resident Areas
Penalty
Summary
The facility failed to ensure an environment free of accident hazards when a shaving razor was observed in Resident #7’s room on multiple observations. Resident #7 was admitted with acute on chronic systolic congestive heart failure, was cognitively intact, and required assistance with oral and personal hygiene. The resident’s care plan focused on arranging the environment to support activities of daily living and keeping frequently used items within reach. Interviews indicated residents were not allowed to keep razors in their rooms, and staff stated that if a razor was used it should be removed afterward; however, the razor remained on the shelf in the resident’s room during repeated observations. The facility also failed to control other hazards in resident areas. Resident #107 was observed with a heating pad on the bed while the resident was in the bathroom, and staff stated the resident used the heating pad daily, although the charge LPNs had no knowledge of its use. Resident #107 had depression, no cognitive impairment, and required varying levels of assistance with ADLs, with a care plan addressing safety and sequencing cueing. In addition, a sharps container in Resident #29’s room was observed filled to capacity, and the DON stated sharps containers should be changed when 3/4 full. An unlocked door on the second-floor south hallway that locked from the inside was also observed in an area containing enteral and medical materials, and staff stated it should be kept locked with a key for resident safety.
Improper Urinary Catheter Tubing Positioning
Penalty
Summary
The facility failed to properly position indwelling urinary catheter tubing to allow free flow of urine for two residents with catheters. Resident #76 was observed in bed with the catheter tubing looped and containing urine, while there was less than 5 mL of urine in the drainage bag. Resident #76’s record showed diagnoses including urinary retention and neuromuscular dysfunction of the bladder, an order to observe the catheter for placement, leakage, or dislodgement every shift, and a care plan directing staff to keep the catheter below bladder level and free of kinks. The resident’s record also showed treatment with antibiotics for a urinary infection in January 2026. Resident #29 was observed seated in a wheelchair with the indwelling urinary catheter tubing extending downward through the resident’s pants and then secured upward on the wheelchair, which prevented urine from flowing freely. Resident #29’s record showed diagnoses including benign prostatic hyperplasia and orders for a suprapubic catheter with monitoring for placement, leakage, or dislodgement every shift. The care plan identified the resident as at risk for infection related to the suprapubic catheter and included instructions to keep the catheter below bladder level and the tubing free of kinks. During interviews, the DON stated the tubing should be straight to prevent backflow of urine and UTI, and the Infection Preventionist stated staff are to ensure tubing is not kinked or coiled to prevent backflow that could cause a UTI.
Unlabeled Resident Food Stored in Nourishment Refrigerator
Penalty
Summary
The facility failed to store food under sanitary condition and failed to ensure resident food items were dated and labeled in the nourishment refrigerator on the Second Floor North Wing. During observation of the nourishment refrigerator, a lunch bag was found inside without a name or date on it. When the bag was opened, it contained several food items, and an LPN stated that it belonged to a resident and should have had a label and date. Record review showed the facility’s policy required prepared food brought in by family or visitors to be labeled with content and dated before being refrigerated. The DON later confirmed that resident food items in the refrigerator and freezer should be labeled and dated.
Missing Hospice Nursing Notes and Poor Care Coordination
Penalty
Summary
The facility failed to collaborate and coordinate with hospice representatives for one resident receiving hospice services by not obtaining and keeping hospice nursing notes in the resident’s hospice folder since the resident started hospice in December 2025. The resident was admitted with diagnoses including Encounter for Palliative Care and Heart Failure, had moderate cognitive impairment on the significant change MDS dated 12/12/25, and was receiving hospice care. The care plan included hospice nurse visits as scheduled, and physician orders dated 12/1/25 and 12/3/25 directed hospice evaluation and hospice admission for Heart Failure. Record review of the hospice folder showed a sign-in sheet documenting hospice nursing visits on 12/11/25, 1/15/26, 1/22/26, and 1/28/26, along with a DNR form and admission doctor’s orders, but no plan of care and no nursing notes were present. On 02/19/26, the second floor Charge LPN stated the resident started hospice in December 2025 and that hospice visits were verified by checking the book, but the frequency of visits and the last visit were unknown. The LPN also stated hospice notes had not been sent despite calling for them. The DON stated hospice staff were to sign, send notes, and give report to floor nurses, and later that day the hospice notes were emailed to the facility.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to demonstrate that effective plans of action were implemented to correctly identify repeated deficient practices in the areas of F880 Infection Prevention & Control, F689 Free of Accident hazards/Supervision/Devices, and F761 Medication Storage. These deficient practices were identified as having the potential to affect 168 residents residing in the facility at the time of the survey. Record review of the facility’s QAPI policy and procedure dated 1/2026 showed that the program was intended to ensure the facility developed a plan for conducting QAPI/QAA activities, including identifying and correcting quality deficiencies and opportunities for improvement, with continuous attention to quality of care, quality of life, and resident safety. Review of the facility’s survey history showed that during a recertification survey with exit dated January 30, 2025, the same areas of F880 Infection Prevention & Control, F689 Free of Accident hazards/Supervision/Devices, and F761 Medication Storage were cited. Review of QAPI Committee Meeting sign-in sheets showed the facility held monthly QAA Committee meetings with attendance by the Administrator, Medical Director, DON, and other department heads. During interview, the Administrator stated QAPI meetings are held each month or as needed and are used to identify and review interventions, evaluate and revise interventions as needed, and monitor progress through input from staff, family, residents, vendors, and daily rounds; the Administrator also stated that some plans of improvement remain ongoing.
Improper Storage of Respiratory and Enteral Equipment
Penalty
Summary
The facility failed to follow infection control protocol for storing medical equipment for two residents. Resident #38 had an uncovered incentive spirometer observed at the bedside on 02/17/2026, and the resident stated on 02/18/2026 that the incentive spirometer is used daily. The Second-Floor Charge LPN stated that respiratory care supplies are to be stored in a plastic bag and the bags are dated for infection control purposes, and the DON stated that respiratory care items are kept in a plastic bag, dated, and changed every seven days. Resident #38’s record showed the resident was admitted with diagnoses including Cerebral Ischemia, had no cognitive impairment on the MDS, received respiratory therapy for seven days, and had a care plan identifying risk for respiratory complications related to a history of Pulmonary Embolism. Resident #46 had an enteral syringe dated 2/16/26 observed on the nightstand on 02/17/2026 and again on 02/18/2026. The resident’s record showed admission and readmission to the facility, diagnoses including encounter for attention to gastrostomy, severe cognitive impairment, dependence in ADLs, and a feeding tube. The care plan stated the resident required an enteral feeding tube for hydration needs and included administration of flushes as ordered and checking tube patency and placement daily and before feedings or medications. Physician orders included water flushes via PEG every shift and Valproic Acid Oral Solution via PEG daily, and the MAR showed daily administration of flushes and medication via PEG. Staff B stated the overnight shift was responsible to change the syringe and that it was checked before medication administration, while the DON stated enteral syringes are not to be used more than 24 hours for infection control and are expected to be changed each night shift.
Failure to Develop and Implement Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was at high risk for falls. Despite having a history of falls and severe cognitive impairment, the resident did not have a fall care plan in place. The resident experienced multiple falls, as documented in the nurses' notes, but the MDS Coordinator did not realize that a specific fall care plan had not been developed, which is a requirement according to the facility's policy. Additionally, the facility failed to implement care plan interventions for two residents with wounds. Both residents were under Enhanced Barrier Precautions (EBP) due to their wounds, which required staff to wear personal protective equipment (PPE) including gowns, masks, and gloves. However, during wound care observations, staff members were noted not wearing the required PPE, which was acknowledged as a mistake by the staff involved. This failure to adhere to EBP was confirmed by the wound care nurse and the infection preventionist. The facility's policy mandates the use of PPE for residents under EBP to prevent infection spread, especially for those with wounds. Despite the availability of PPE in the hallway caddy, staff members admitted to forgetting to wear the necessary equipment during care, which was also confirmed by the Director of Nursing. This oversight in implementing the care plan interventions for wound care represents a significant deficiency in the facility's adherence to infection control protocols.
Infection Control Breach: Unlocked Soiled Utility Rooms
Penalty
Summary
The facility failed to implement infection control standards and procedures related to the security of Soiled Utility Rooms. During a focused observation, it was found that the three Soiled Utility Rooms in the facility were unlocked. This was confirmed during a tour with the surveyor and the Registered Nurse Infection Control Preventionist, who acknowledged that the rooms were left unlocked during the day. An interview with a Licensed Practical Nurse Supervisor on the first floor revealed that the soiled utility room doors are supposed to remain locked, and staff must request access from the nurses or the supervisor. However, the rooms were observed to be unlocked, indicating a lapse in following the facility's infection prevention and control policy, which mandates maintaining a safe and sanitary environment to prevent the transmission of infections.
Failure to Maintain Safe Environment Due to Improper Razor Storage
Penalty
Summary
The facility failed to provide an environment free from accident hazards for a resident, as evidenced by the presence of an electric and a disposable razor on the resident's nightstand. Observations on two consecutive days revealed that the razors remained on the nightstand, despite the facility's policy that razors should be kept by staff at all times. The resident, who is cognitively intact but requires moderate assistance for care, has a history of Parkinson's disease with dyskinesia and Type 2 Diabetes. The resident's care plan indicates a self-care performance deficit and impaired mobility, necessitating assistance with activities of daily living. Interviews with the Director of Nursing and a Certified Nursing Assistant revealed that the resident prefers to shave himself and that his son provided a personal electronic razor due to the resident's use of anticoagulants and risk for bleeding. The CNA stated that razors are typically stored in the supply room and that she checks on the resident to ensure he has finished shaving, removing the razors if left out. Despite these measures, the razors were observed on the nightstand, indicating a lapse in adherence to the facility's policy and procedures regarding maintaining a safe environment.
Oxygen Therapy Not Administered as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received oxygen therapy as prescribed. During several observations, it was noted that the resident's oxygen was administered at 2 liters per minute (LPM) via nasal cannula, contrary to the physician's order of 3 LPM. This discrepancy was observed on multiple occasions, including when the resident was asleep and awake, with no signs of distress noted. The resident, who was moderately cognitively impaired and dependent on assistance for activities of daily living, had a medical history that included respiratory disorders and respiratory failure with hypoxia. The deficiency was confirmed during an interview and observation with a registered nurse, who acknowledged the discrepancy between the prescribed oxygen rate and what was being administered. The facility's policy on oxygen administration requires that oxygen be administered under a physician's orders, except in emergencies. Despite this policy, the resident's oxygen was not provided at the correct rate, as per the physician's orders, indicating a lapse in adherence to the facility's procedures and protocols for oxygen administration.
Expired Nutritional Supplements Found in Medication Storage
Penalty
Summary
The facility failed to ensure the proper rotation of dietary medication supplements, resulting in two expired Vanilla Nutritional Drinks being found in the first floor's medication storage room. This was observed during a survey conducted with a Registered Nurse (Staff A), who confirmed that these supplements are used for residents during medication administration, particularly for those who do not want their medications with water. Despite the facility's policy requiring daily checks of medication storage rooms by nurses and additional checks by the central supply clerk and nursing supervisors on Mondays and Fridays, the expired supplements were not identified and removed in a timely manner. At the time of the survey, there were 98 residents residing in the facility.
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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 North Miami
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Dade Nursing And Rehabilitation Center | 0.8 mi | ★★★★★ | 9 | 0 |
| Aventura Rehab And Nursing Center | 1.2 mi | ★★★★★ | 8 | 0 |
| Biscayne Health And Rehabilitation Center | 1.3 mi | ★★★★★ | 9 | 0 |
| Serenity Bay Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 14 | 0 |
| Villa Maria Nursing Center | 1.5 mi | ★★★★★ | 4 | 2 |
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