Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 University Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that two soiled utility rooms on an upper floor were repeatedly left unlocked because paper towels had been inserted into the door locks, preventing them from securing properly. A Wound Care RN, a CNA, and another staff member each exited a soiled utility room without ensuring the door was locked, and later the same RN left a second soiled utility room unsecured, with paper towels again blocking the lock. During interviews, the RN acknowledged the rooms are supposed to remain locked, and the DON confirmed that these rooms contain sharps containers and biohazard materials and are required to be kept locked with a code lock system, contrary to what was observed.
Surveyors found four bouquets of flowers stored on shelves with fruits and vegetables in the walk-in refrigerator, contrary to the facility's food storage policy. Both the Dietary Supervisor and Corporate CDM confirmed that the flowers, intended for Nurses' week, should not have been in the refrigerator. This issue had the potential to affect most residents who were eating orally.
Confidential paperwork with residents' names, photos, and room numbers was left unattended and visible on a medication cart by an RN, making private information accessible to unauthorized individuals. The DON confirmed that all resident information should remain confidential, in line with facility policy.
A resident with severe cognitive impairment and a history of heart failure continued to have a BiPAP machine and related interventions listed in their care plan after physician orders discontinued its use. The BiPAP machine remained in the room, and staff were unclear about its status, leading to outdated care plan documentation that did not reflect current orders or the resident's needs.
A plastic bag containing loose pills and medications in containers was found left unattended on top of a medication cart on the fourth floor. An RN had removed the medications from a resident's room but left them unsecured on the cart after being called away for an emergency. Facility policy and the DON require all medications to be kept in a locked cart, but this was not followed.
The facility experienced repeated deficiencies in food storage practices, including unsanitary conditions in the ice cream freezer and improper storage of flower bouquets with produce in the walk-in refrigerator, affecting most residents who eat orally. The QAPI committee, despite regular meetings with department heads, failed to monitor and resolve these recurring issues, leading to continued noncompliance.
A resident with dementia hit her head on a wheelchair armrest during an assisted transfer, but the incident was not immediately reported by the CNA. The injury was only identified after a family member noticed bruising. The facility's protocol for reporting incidents was not followed, leading to a delay in notifying the resident's physician and representative.
A resident with dementia and impaired mobility was injured during a transfer when a CNA failed to properly position a wheelchair and let go of the resident, causing her to hit her head. The incident was not reported immediately, and injuries were discovered later by a family member. The facility's protocol for accident reporting was not followed, highlighting a lapse in supervision and communication.
A resident sustained injuries during a transfer when a CNA failed to position the wheelchair correctly and let go of the resident, causing her to hit her arm on the wheelchair's armrest. The incident was not reported immediately, and the injuries were discovered by a family member. The resident required substantial assistance for transfers, and the facility's policies emphasize safety and supervision, which were not followed in this case.
A resident in an LTC facility was injured during a transfer when she hit her arm on a wheelchair. The CNA did not properly position the wheelchair and failed to report the incident to the nurse, leading to a delay in informing the resident's family and physician. The facility's protocol for reporting and documenting incidents was not followed.
Unsecured Soiled Utility Rooms Due to Tampered Door Locks
Penalty
Summary
The deficiency involves the facility’s failure to maintain soiled utility rooms in a safe, locked condition as required by facility policy. On the facility’s second floor, surveyors observed that two of five soiled utility room doors were not secured because pieces of paper towel had been placed in the locks, preventing them from locking properly. On one occasion, at 1:40 PM, the Wound Care RN completed wound care, disposed of a biohazard bag in a soiled utility room, and exited without ensuring the door was locked. Shortly afterward, at 1:45 PM and 1:46 PM, a CNA and another staff member exited the same soiled utility room and also left the door unlocked. At 1:47 PM, it was observed that a paper towel had been inserted into the lock of this soiled utility room door, preventing proper locking, and when the ADON, CNA, Wound Care RN, and another staff member examined the lock together, none knew who had placed the paper towel there. Later that afternoon, at 2:09 PM, the Wound Care RN exited a second soiled utility room on the same floor and again did not lock the door. The surveyor checked this second room’s lock and found another piece of paper towel blocking the lock, which also prevented the door from locking, and this was documented with a photo. In an interview, the Wound Care RN stated that the soiled utility room is supposed to be kept locked and acknowledged not checking the door because they did not expect paper towels to be in the lock. The DON confirmed that the soiled utility room doors are equipped with code locks and are to remain locked to prevent resident entry, noting that sharps containers and biohazard materials are stored inside. The facility’s written Safety – Prevention of Accidents policy states that the environment is to be made as free from accident hazards as possible, that employees are to be trained to identify and report hazards and prevent avoidable accidents, and that interventions to reduce accident risks must be implemented and monitored, underscoring that the unsecured soiled utility rooms were inconsistent with the facility’s stated safety practices.
Improper Storage of Non-Food Items in Walk-In Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to store food under sanitary conditions in the walk-in refrigerator, where four bouquets of flowers were found lying on the shelves among fruits and vegetables. This was identified during an initial kitchen tour with the Dietary Supervisor and Corporate CDM, who both confirmed that the flowers should not have been stored in the refrigerator. The facility's Food Storage Policy requires that food storage areas be maintained in a clean, safe, and sanitary manner, and that perishable foods are stored immediately after delivery. The presence of non-food items, specifically flower bouquets intended for Nurses' week, among food items was documented with photographic evidence. This deficiency had the potential to affect 128 out of 133 residents who were eating orally at the time of the survey.
Failure to Secure Resident Confidential Information
Penalty
Summary
Confidential paperwork containing residents' names, photographs, and room numbers was observed left unattended and visible on top of the fourth floor's south medication cart. This incident occurred while the cart was unattended, making the information accessible to unauthorized individuals. A registered nurse acknowledged leaving the paperwork on the cart and recognized that all resident information should be kept private. The Director of Nursing confirmed that all resident information is expected to remain confidential. Facility policy reviewed indicated that protected health information (PHI), including electronic PHI, must be safeguarded to prevent unauthorized access.
Failure to Update Respiratory Care Plan After Discontinuation of BiPAP
Penalty
Summary
The facility failed to update the respiratory care plan for a resident after physician orders discontinued the use of a BiPAP machine. Despite the discontinuation order dated 10/15/24, the resident's care plan continued to include interventions for BiPAP use, and the machine remained present in the resident's room. Multiple observations over several days confirmed the BiPAP machine and its tubing were still at the bedside, with the mask stored in a drawer. Staff interviews revealed that the night supervisor believed the BiPAP was still being applied at night, although there were no active physician orders for its use. The MDS coordinator acknowledged that the care plan interventions for the BiPAP were only resolved months after the discontinuation order, and the DON confirmed the machine was left in the room due to family circumstances, but staff were not to administer it without an order. The resident involved had diagnoses including heart failure and insomnia, was severely cognitively impaired, and did not exhibit shortness of breath or require respiratory therapy according to recent assessments. The facility's policy required ongoing assessment and timely revision of care plans as resident conditions changed, but this was not followed in this case, resulting in outdated care plan interventions for respiratory therapy that no longer reflected the resident's current physician orders or needs.
Unsecured Medications Left Unattended on Medication Cart
Penalty
Summary
A plastic bag containing medications was observed left unattended on top of the south medication cart on the fourth floor, where 24 residents resided. The bag included loose pills and pills in containers. The medication cart was unattended at the time of observation. A Registered Nurse (RN) at the nursing station confirmed that the bag contained medications, which she had found in a resident's room. The RN stated she removed the medications from the room with the intention of notifying the supervisor but was called away to assist with an emergency, leaving the medications unsecured on the cart. Further interview with the RN revealed that any medications found in residents' rooms should be given to the supervisor and not left on the cart. The Director of Nursing (DON) confirmed that medications are to be kept in a locked cart and, if found in a resident's room, should be secured and labeled until picked up by family. Facility policy requires all drugs and biologicals to be stored in a safe, secure, and orderly manner, with nursing staff responsible for maintaining medication storage areas. The observed practice did not comply with these requirements.
Repeated Deficiencies in Food Storage and QAPI Oversight
Penalty
Summary
The facility failed to implement effective action plans to correct previously identified quality deficiencies, specifically in the areas of food storage and the operation of its Quality Assurance and Performance Improvement (QAPI) committee. During a prior recertification survey, the facility was cited for not storing food under sanitary conditions, as evidenced by a buildup of ice in the ice cream freezer, which had the potential to affect nearly all residents who consumed food orally. In the most recent survey, a similar deficiency was observed, with flower bouquets being stored on shelves among fruits and vegetables in the walk-in refrigerator, again potentially impacting the majority of residents who eat orally. Additionally, the QAPI committee was cited for failing to adequately monitor and address these recurring problem areas. Despite holding monthly meetings with participation from key department heads, the committee did not ensure that previously identified issues were effectively resolved or that ongoing performance improvement projects were sufficiently evaluated. This lack of sustained oversight contributed to the recurrence of the same deficiencies.
Failure to Report Resident Injury During Transfer
Penalty
Summary
The facility failed to immediately inform a resident's representative and physician about an accident that resulted in an injury requiring medical attention. The incident involved a resident who, during an assisted transfer, hit her head on the armrest of a wheelchair. This incident went unreported initially, and the bruising was only identified after a family member noticed it and reported it to the staff. The resident, who has a diagnosis of dementia and is moderately impaired cognitively, required substantial assistance for transfers and was at low risk for falls according to a recent assessment. On the day of the incident, the resident was being transferred by a CNA who did not properly position the wheelchair before the transfer. The CNA held the resident with one hand and the wheelchair with the other, leading to the resident losing control and hitting her head. The CNA did not report the incident immediately as she did not observe any immediate bruising or injury. It was only after the family member's observation that the incident was reported, and an assessment was conducted. The Director of Nursing confirmed that the protocol for reporting such incidents was not followed, as the CNA failed to notify the facility about the incident on the day it occurred. The incident was only documented after the family member's report, and subsequent assessments, including an x-ray, were conducted. The facility's policy requires all accidents or incidents to be reported and investigated, but this protocol was not adhered to in this case.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. IMMEDIATE CORRECTIVE ACTION: Staff A was counseled by Director of Nursing and competency was completed regarding safe patient transfers and reporting of incidents on Resident #1 did not have any negative outcomes related to the alleged deficient practice. Staff B received 1:1 education from the Director of Nursing regarding proper notification of changes in condition to physician and resident's representative according to facility policy on. Nursing staff was in-serviced by the Director of Nursing regarding proper notification of changes in condition to physician and resident's representative according to facility policy on. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED: Any resident in the facility have the potential to be affected by the alleged deficient practice. A facility wide audit was conducted on to identify any residents with change in condition without proper notification of physician and resident's representative. No issues were identified. SYSTEMATIC CHANGES: The Assistant Director of Nursing conducted ongoing in-services with nursing staff regarding safe transfers and proper notification of resident's representative and physician. The Director of Nursing/Designee will review all new incidents/changes in condition during the morning meeting to ensure proper notification of resident's representative and physician according to facility policy. MONITORING: The Director of Nursing/Designee will conduct daily rounds and chart review x 5 days, then weekly x 4 weeks, then random biweekly review, to ensure that physician and resident's representative are promptly notified of significant changes in condition. The Director of Nursing/Designee will report findings to the Quality Assurance committee monthly for 3 months to ensure substantial compliance is achieved and maintained.
Inadequate Supervision During Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident during a transfer, resulting in injuries that were not immediately reported by staff. The resident, who was moderately impaired cognitively and required substantial assistance for transfers, sustained a head injury when a CNA attempted to transfer her from the bed to a wheelchair. The CNA did not position the wheelchair correctly and let go of the resident, causing her to hit her head on the wheelchair's armrest. The incident was not reported immediately, and the injuries were discovered later by a family member. The resident had a history of dementia and was at risk for falls due to muscle weakness and impaired mobility. Despite being on fall precautions, the CNA did not follow proper transfer procedures and failed to report the incident to the nursing staff. The resident's care plan included interventions to encourage her to ask for assistance during transfers, but these were not effectively implemented. The CNA admitted to not reporting the incident because she did not notice any immediate bruising or injuries. The incident was eventually reported to the Director of Nursing and the physician, who ordered x-rays that showed no fractures. However, the delay in reporting and assessing the resident's injuries highlights a lapse in the facility's protocol for accident and incident reporting. The facility's policy requires all accidents or incidents to be investigated and reported promptly, but this was not adhered to in this case.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. **IMMEDIATE CORRECTIVE ACTION:** Staff A was counseled by Director of Nursing and competency was completed regarding safe patient transfers on Resident #1 did not have any negative outcomes related to the alleged deficient practice. Nursing staff was in-serviced by the Director of , with competency completed on safe resident transfers on and. **IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED:** Any resident requiring assistance with transfers have the potential to be affected by the alleged deficient practice. A facility wide audit was conducted on to identify any residents needing assistance with transfer to ensure that staff are aware and that facility policy is being followed. **SYSTEMATIC CHANGES:** The Assistant Director of Nursing conducted ongoing in-services with nursing staff regarding safe transfers and proper notification of resident's representative and physician. Nursing staff was in-serviced by the Director of , with competency completed on safe resident transfers on and. **MONITORING:** The Director of Nursing/Designee will conduct weekly random observation and competency checks with nursing staff x four weeks, then monthly random observation and competency checks x 3 months to ensure nursing staff are transferring residents safely according to facility policy and procedures. The Director of Nursing/Designee will report findings to the Quality Assurance committee monthly for 3 months to ensure substantial compliance is achieved and maintained.
Resident Injury During Unsafe Transfer
Penalty
Summary
The facility staff failed to operate equipment safely, resulting in a resident sustaining injuries during a transfer. The incident involved a Certified Nursing Assistant (CNA) who was transferring the resident from the bed to a wheelchair. During the transfer, the CNA did not position the wheelchair correctly and let go of the resident momentarily, causing the resident to hit her arm on the wheelchair's armrest. This incident was not immediately reported by the CNA, and the injuries were later discovered by a family member. The resident involved in the incident required substantial to maximal assistance for chair or bed-to-chair transfers, as indicated in their care plan. The care plan also highlighted the resident's risk related to mobility and included interventions such as encouraging the resident to ask for assistance when attempting to transfer. Despite these precautions, the CNA did not follow the correct procedure for transferring the resident, which contributed to the accident. The facility's policies on safety and supervision of residents emphasize the importance of making the environment as free from accident hazards as possible. However, the CNA failed to report the incident to the nurse, which was against the facility's policy on accidents and incidents. The Director of Nursing confirmed that the CNA was reprimanded for not reporting the incident, and the incident was later documented in the facility's incident log.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. **IMMEDIATE CORRECTIVE ACTION:** Staff A was counseled by Director of Nursing and competency was completed regarding safe patient transfers on Resident #1 did not have any negative outcomes related to the alleged deficient practice. Nursing staff was in-serviced by the Director of with competency completed on safe resident transfers on and. **IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED:** Any resident requiring assistance with transfers have the potential to be affected by the alleged deficient practice. A facility wide audit was conducted on to identify any residents needing assistance with transfer to ensure that staff are aware and that facility policy is being followed. **SYSTEMATIC CHANGES:** The Assistant Director of Nursing conducted ongoing in-services with nursing staff regarding safe transfers and proper notification of resident's representative and physician. Nursing staff was in-serviced by the Director of with competency completed on safe resident transfers on and. **MONITORING:** The Director of Nursing/Designee will conduct weekly random observation and competency checks with nursing staff x four weeks, then monthly random observation and competency checks x 3 months to ensure nursing staff are transferring residents safely according to facility policy and procedures. The Director of Nursing/Designee will report findings to the Quality Assurance committee monthly for 3 months to ensure substantial compliance is achieved and maintained.
Failure to Report Resident Injury
Penalty
Summary
The facility failed to immediately inform the resident's representative and physician about an accident that resulted in an injury requiring medical attention for one resident. During an assisted transfer, the resident hit her arm on the wheelchair, and the incident went unreported until a family member identified and reported it to the staff. The resident was observed with a small discoloration under the right eye and scratches on both arms. The resident required substantial assistance for chair/bed-to-chair transfers and had a care plan indicating a risk for falls related to mobility. Despite this, the Certified Nursing Assistant (CNA) did not properly position the wheelchair before transferring the resident, leading to the incident. The CNA failed to report the incident to the nurse, which was a breach of protocol. The Director of Nursing (DON) confirmed that the protocol required staff to report such incidents to the doctor and family, complete an incident report, and document the occurrence. However, there was no documentation related to the incident in the progress notes, and the CNA was reprimanded for not reporting the incident. The facility's policy required all accidents or incidents to be investigated and reported, but this was not adhered to in this case.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. **IMMEDIATE CORRECTIVE ACTION:** Staff A was counseled by Director of Nursing and competency was completed regarding safe patient transfers and reporting of incidents on. Resident #1 did not have any negative outcomes related to the alleged deficient practice. Staff B received 1:1 education from the Director of Nursing regarding proper notification of changes in condition to physician and resident's representative according to facility policy on. Nursing staff was in-serviced by the Director of Nursing regarding proper notification of changes in condition to physician and resident's representative according to facility policy on. **IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED:** Any resident in the facility have the potential to be affected by the alleged deficient practice. A facility wide audit was conducted on to identify any residents with change in condition without proper notification of physician and resident's representative. No issues were identified. **SYSTEMATIC CHANGES:** The Assistant Director of Nursing conducted ongoing in-services with nursing staff regarding safe transfers and proper notification of resident's representative and physician. The Director of Nursing/Designee will review all new incidents/changes in condition during the morning meeting to ensure proper notification of resident's representative and physician according to facility policy. **MONITORING:** The Director of Nursing/Designee will conduct daily rounds and chart review x 5 days, then weekly x 4 weeks, then random biweekly review, to ensure that physician and resident's representative are promptly notified of significant changes in condition. The Director of Nursing/Designee will report findings to the Quality Assurance committee monthly for 3 months to ensure substantial compliance is achieved and maintained.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Miami
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jackson Gardens Health And Rehabilitation Center | 0.1 mi | ★★★★★ | 7 | 0 |
| Unity Healthcare And Rehabilitation Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Riverside Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Victoria Nursing & Rehabilitation Center, Inc. | 1.2 mi | ★★★★★ | 0 | 0 |
| Jackson Memorial Long Term Care Center | 1.5 mi | ★★★★★ | 4 | 0 |
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