Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Villa Maria Nursing Center during CMS and state inspections, most recent first.
A resident with dementia and an unsteady gait, identified as high risk for elopement, exited the facility undetected after a group activity. Staff did not immediately notice the absence, and the resident was later found by law enforcement wandering in a busy neighborhood, despite existing care plan interventions and facility policies intended to prevent such incidents.
A resident with dementia and an unsteady gait, identified as high risk for elopement, was able to leave the facility undetected after a group activity. Despite existing policies and a care plan for elopement risk, staff failed to provide adequate supervision and monitoring, and security procedures at the facility gate were insufficient. The resident was later found by law enforcement in a nearby neighborhood and transported to a hospital for evaluation.
A resident with dementia and a known risk for wandering was able to leave the facility undetected after an activity, due to inadequate supervision and lapses in security procedures. The resident exited through an electronic gate while staff were distracted, and was later found in a nearby neighborhood and transported to a hospital. The facility failed to follow established protocols for monitoring and supervising high-risk residents, resulting in the resident's elopement.
The QAA Committee did not effectively identify or address ongoing supervision deficiencies, leading to repeated incidents, including the elopement of a resident with exit-seeking behaviors who left the facility undetected through an electronic gate. This pattern of inadequate oversight and failure to implement corrective actions has the potential to impact all residents.
A resident who eats independently was not served a meal during a scheduled dining period, while their tablemate received and began eating their meal. Staff interviews revealed the omission was due to a kitchen error and confusion regarding the resident's assigned dining location, resulting in the resident not receiving a meal tray as required by facility policy.
Surveyors found several resident areas in unsanitary and disrepair conditions, including water damage, detached air conditioning units, stained furniture, and exposed wall surfaces. Interviews with environmental services and maintenance staff confirmed ongoing issues with room cleanliness and timely repairs, resulting in a failure to provide a safe, clean, and homelike environment.
Two residents with significant cognitive and physical impairments were exposed to accident hazards when a required floor mat was not properly positioned for one resident at risk for falls, and an open container of hazardous disinfectant wipes was left on another resident's bedside table. Staff interviews and facility policy confirmed that these actions did not meet established safety protocols.
A resident with acute respiratory failure did not receive oxygen therapy as prescribed, as the nasal cannula was observed out of the nostrils or in the mouth on multiple occasions while oxygen was running. Staff did not identify the improper placement until alerted by a surveyor, despite regular checks and physician orders for continuous oxygen via nasal cannula.
A resident was not provided with a meal tray in a timely manner while seated at a table for two, resulting in her table mate being served and eating before her. This incident, along with a previous issue involving an uncovered urinary catheter drainage bag, demonstrates the facility's failure to implement effective QAPI actions to address dignity-related deficiencies.
Two residents receiving enteral tube feedings were observed with improper infection control practices, including an uncapped and leaking feeding tube and uncovered feeding tube caps left on a bedside chair. Staff interviews confirmed that these practices did not align with facility protocols, and the DON acknowledged the infection control concerns.
A Life Safety Code survey identified that a facility's fire alarm system and fire panel were not properly maintained, resulting in non-operational magnetic door locks and flashing lights on exit doors. The Maintenance Supervisor acknowledged repeated malfunctions and unsuccessful repair attempts, leading to Immediate Jeopardy. The Nursing Home Administrator noted that the facility was seeking estimates for a replacement fire panel. Despite routine inspections, there was a lack of communication with residents and their families about the system failures, highlighting significant safety risks in the event of a fire emergency.
The facility failed to maintain a functional fire alarm system, impacting the safety and well-being of residents, staff, and visitors. Despite routine inspections and repair attempts, the outdated motherboard could not be fixed or integrated with a new panel. The facility is in the process of obtaining estimates and bids for a new wireless fire alarm system.
A facility failed to ensure dignity for a resident with an indwelling catheter by not fully covering the urinary drainage collection bag with a dignity bag, despite the resident's preference for privacy and the facility's protocol requiring it.
The facility failed to transmit the Discharge-Return Anticipated MDS to CMS within the required 14-day period for a resident discharged to a short-term general hospital. The delay was due to an oversight by the MDS Coordinator, as confirmed by the Regional MDS Coordinator.
The facility failed to accurately code the MDS for three residents, leading to deficiencies in their care plans. One resident's use of dentures was not documented, another resident's tobacco use was inaccurately recorded, and a third resident's oxygen therapy was not coded in the MDS.
The facility failed to follow physician orders for bilateral floor mats for four residents at risk for falls. Observations showed mats were often not in place, and staff interviews revealed inconsistencies in ensuring mats were replaced after being removed for care or cleaning.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A cognitively impaired resident with diagnoses including dementia and an unsteady gait exited the facility undetected by staff. The resident had a documented history of elopement risk, as indicated in the care plan and elopement risk assessment, which included interventions such as placing a photograph on a wander list, using a pink armband, and redirecting attention away from exit areas. On the day of the incident, the resident participated in a bingo activity and was left waiting to be transported back to their room. Staff later discovered the resident's wheelchair empty and initiated a search, but the resident was not found within the facility. The facility's timeline and staff interviews revealed that there was a delay in recognizing the resident's absence and activating the Code Pink alert. Staff checked the resident's room and surrounding areas before initiating a facility-wide search. The security officer on duty did not observe the resident leaving, as attention was divided between managing gate access for a transport van and a visitor. The resident was able to exit the facility and travel approximately 0.7 miles away, eventually being found by law enforcement wandering in a high-traffic neighborhood. Record reviews and staff interviews confirmed that the resident was at high risk for elopement and that staff were aware of this risk. Despite existing policies and care plan interventions, the resident was able to leave the facility without detection, indicating a failure to provide adequate supervision and a secure environment. The incident resulted in the resident being exposed to significant environmental hazards before being located and returned to the facility.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with diagnoses of dementia and an unsteady gait, identified as high risk for elopement, was able to leave the facility undetected by staff. The resident had a documented care plan indicating elopement risk, including interventions such as placement on a wander list, use of a pink armband, and staff monitoring. On the day of the incident, the resident participated in a bingo activity and was left waiting in a wheelchair after the activity concluded. Staff discovered the wheelchair empty and, after searching the immediate area and the resident's room, activated a Code Pink to report the missing resident. Despite the facility's policies and procedures for elopement prevention and accident hazard reduction, the monitoring and supervision provided were insufficient. Staff interviews revealed that although multiple staff members were present during the activity and responsible for transporting residents back to their rooms, the resident was able to leave the area without being noticed. Security procedures at the facility gate were also inadequate, as the security officer was distracted by managing both incoming and outgoing traffic, allowing the resident to exit the premises without detection. The resident was found by law enforcement approximately 0.7 miles from the facility, wandering in a high-traffic neighborhood, and was subsequently transported to a hospital for evaluation. The incident demonstrated a failure to provide a secure environment and adequate supervision for a resident at known risk for elopement, as required by facility policy and regulatory standards. The lack of effective monitoring and communication among staff contributed to the resident's unauthorized departure and delayed response in locating the individual.
Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to implement and ensure effective and efficient preventative measures to prevent the neglect and elopement of a resident who was identified as high risk for elopement due to a diagnosis of dementia and a history of wandering. The resident's care plan included interventions such as placing a photograph on a wander list, redirecting attention away from exit areas, assisting with meaningful activities, and alerting staff to monitor the resident's location. Despite these interventions, the resident was left unsupervised after an activity, and staff did not maintain the assigned level of supervision. On the day of the incident, the resident participated in a Bingo activity that concluded at 4:00 PM. The resident was waiting to be transported back to their room, but when staff arrived, only the resident's empty wheelchair was found. Staff searched the surrounding areas and the resident's room before activating a Code Pink at 4:45 PM. The facility is located in a high-traffic area, increasing the risk associated with elopement. The resident was able to exit the facility undetected through an electronic gate at the front of the building. The security officer on duty was distracted by managing both an outgoing transport van and an incoming visitor, resulting in both gates being open simultaneously and a lapse in monitoring the exit. The resident was later found in a nearby residential neighborhood and transported to a local hospital for evaluation. Interviews with staff revealed gaps in supervision and communication, as well as a lack of adherence to established protocols for monitoring high-risk residents. The facility's failure to ensure that residents were not able to leave the premises and to implement the assigned level of supervision directly contributed to the resident's elopement and placed the resident at risk for harm.
Failure to Identify and Address Supervision Deficiencies Resulting in Resident Elopement
Penalty
Summary
The facility's Quality Assurance and Assessment (QAA) Committee failed to identify and address quality concerns related to adequate supervision of residents, resulting in repeated deficient practices. Despite having a QAPI program and holding regular QAA Committee meetings with interdisciplinary attendance, the committee did not effectively track, measure, or prioritize quality deficiencies, nor did it systematically analyze underlying causes. This lack of effective oversight led to ongoing issues with supervision and accident prevention, as evidenced by a history of citations for related deficiencies. On August 4, 2025, the facility failed to provide adequate supervision and effective services to prevent the elopement of a resident with known exit-seeking behaviors. The resident was able to leave the facility undetected through an electronic gate in the front of the building. This incident, along with previous citations for similar issues, demonstrates a pattern of insufficient supervision and failure to implement effective corrective actions, potentially affecting all 191 residents in the facility.
Resident Not Served Meal During Scheduled Dining Period
Penalty
Summary
During a lunch meal observation, a resident who eats independently did not receive a meal tray while seated in the dining room. The resident's tablemate was served and began eating, but the resident was left without a meal. Staff interviews revealed that the resident's tray was not included in the meal cart due to a kitchen error. The seating arrangement confirmed the resident was assigned to the table according to the facility's dining plan, but the meal was not delivered as expected. Further interviews with staff, including a CNA and the Food Service Director, indicated that meal trays were distributed based on a list provided by the charge nurse. The kitchen staff followed this list to serve meals, but an oversight led to the omission of the resident's tray. The Director of Nursing noted that the resident was present in the dining room during meal service, although this was not their assigned dining location, which contributed to the error. The facility's policy requires that residents be treated with dignity and respect, but this was not upheld in this instance.
Failure to Maintain Sanitary and Homelike Resident Environment
Penalty
Summary
Surveyors observed multiple resident areas on the facility's third floor North and East Units that were unsanitary and in disrepair. Specific findings included water damage to walls, water on the floor under air conditioning units, detached baseboards, and air conditioning units that were either falling off or detached from the wall. Additional observations included a heavily stained bedside chair and a hand sanitizer dispenser that had been ripped off the wall, exposing the concrete underlayer. Photographic evidence was collected for these deficiencies. Interviews with the Director of Environmental Services and the Director of Maintenance revealed that housekeeping staff are scheduled daily to clean and sanitize resident rooms, bathrooms, and common areas, including cleaning all furniture. The Director of Maintenance described a process for reporting and addressing maintenance issues, noting that some air conditioning units in resident rooms required repair. Despite these processes, the observed deficiencies indicated that the facility failed to maintain a safe, clean, and homelike environment for residents as required by policy.
Failure to Maintain Safe Environment and Prevent Accident Hazards
Penalty
Summary
The facility failed to provide a safe environment in accordance with its own policies regarding accident hazards for two vulnerable residents. For one resident with a history of falls and significant cognitive impairment, observation revealed that while the resident was in bed, a required floor mat was not properly positioned; instead, it was placed against the wall rather than beside the bed as ordered. Staff interviews confirmed that floor mats are to be placed on both sides of the bed when the resident is in bed, and stored away only when the resident is out of bed. The resident’s care plan and physician’s orders specifically required bilateral floor mats due to the resident’s high risk for falls and decreased safety awareness. For another resident with severe cognitive impairment and total dependence for activities of daily living following a cerebral infarction, an open container of disinfectant wipes was found on the bedside table. The wipes contained hazardous chemicals, including high concentrations of ethyl alcohol and quaternary ammonium compounds, with manufacturer warnings indicating the need for secure storage. Staff interviews confirmed that such disinfectant wipes are not permitted in resident rooms due to the risk of inappropriate use, especially for residents who are not alert and oriented. Facility policy also prohibits hazardous items from being kept in resident rooms and requires staff to routinely check for such hazards. Both incidents were identified through direct observation, record review, and staff interviews, demonstrating a failure to adhere to facility policies and procedures designed to minimize accident hazards and ensure resident safety. The deficiencies involved lapses in environmental safety checks and improper storage of hazardous materials, directly affecting residents with significant cognitive and physical impairments.
Failure to Ensure Proper Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure that oxygen therapy was delivered as prescribed for a resident with a primary diagnosis of acute respiratory failure. Observations on two separate occasions revealed that the resident's nasal cannula was not properly positioned in the nostrils while oxygen was running at 2 liters per minute, as ordered by the physician. On one occasion, the nasal cannula was not in the resident's nostrils, and on another, it was observed in the resident's mouth. In both instances, staff were alerted by the surveyor to correct the placement of the oxygen tubing. Medical record review confirmed that the resident was admitted with acute respiratory failure and had physician orders for continuous oxygen via nasal cannula. The resident's care plan included interventions to administer oxygen as ordered and monitor for signs of respiratory distress. Staff interviews indicated that routine checks and vital sign monitoring were performed, but the improper placement of the nasal cannula was not identified by staff prior to surveyor intervention. The facility's policy required provision of respiratory therapy services as ordered by a physician.
Repeated Failure to Ensure Resident Dignity During Meal Service
Penalty
Summary
The facility failed to implement effective actions through its Quality Assurance and Performance Improvement (QAPI) program to address previously identified quality deficiencies related to resident dignity. During a prior recertification survey, the facility was cited for not ensuring dignity when a resident's indwelling urinary catheter drainage collection bag was not fully covered with a privacy bag. In the most recent survey, a similar deficiency was identified under F550 (Resident Rights), where a resident was not provided with a meal tray in a timely manner during dining. The resident was seated at a table for two in the dining room, and while her table mate was served and had started eating, she was left without a meal tray. Observations, interviews, and record reviews confirmed that the QAA committee, which includes interdisciplinary members and meets monthly, had not ensured that effective corrective actions were implemented to prevent recurrence of dignity-related deficiencies. Despite the facility's policy outlining systematic processes for evaluating care and addressing root causes, the repeated citation indicates that the measures in place were insufficient to ensure all residents received dignified care, particularly during meal service.
Failure to Maintain Infection Control for Enteral Feeding Tubes
Penalty
Summary
The facility failed to follow infection control standards and procedures for two residents receiving enteral tube feedings. For one resident with multiple sclerosis and a gastrostomy, observation revealed the feeding tube was left uncapped and leaking on the feeding pump, with dry residue noted on the pump surface. The resident's care plan identified risks related to the gastrostomy tube, including the need for daily cleansing and monitoring for infection, but these precautions were not observed during the survey. Physician orders specified continuous enteral feeding, and the resident was dependent on activities of daily living and received more than half of nutritional intake via tube feeding. For another resident with a gastrostomy, multiple observations showed enteral feeding tubing caps stored uncovered on the bedside chair, both when the feeding was inactive and running. Staff interviews indicated that the standard practice was to clean and cap the feeding equipment and store unused caps in a sanitary manner, but this was not followed as evidenced by the uncovered caps. The Director of Nursing confirmed that feeding tubes should always be capped or placed in a protective bag if a cap is unavailable, acknowledging the infection control concerns presented by the photographic evidence.
Fire Alarm System Malfunction Poses Safety Risks
Penalty
Summary
The facility failed to ensure a safe environment for all occupants by neglecting to maintain the Fire Alarm system and the faulty fire panel, placing residents, staff, and visitors at risk in the event of a fire. The deficiency was identified during a Life Safety Coded survey on March 12, 2024, where it was discovered that the magnetic door locks on exit doors and flashing lights were not operational, hindering individuals from exiting the facility safely during emergencies. The facility's Maintenance Supervisor acknowledged that the fire alarm had experienced repeated malfunctions, with attempts made to repair the system but without successful completion, leading to the determination of Immediate Jeopardy starting on January 5th, 2024. The Nursing Home Administrator disclosed that the facility was in the process of seeking estimates and bids for the replacement of the fire panel, which was deemed outdated and unable to function properly. Despite routine maintenance inspections, the facility failed to notify residents, their families, or representatives of the system failures, indicating a lack of communication regarding critical safety issues within the facility. The deficiency highlighted a significant risk to the safety and well-being of all occupants due to the non-functioning fire alarm system and panel, posing serious threats in the event of a fire emergency.
Failure to Maintain Functional Fire Alarm System
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, impacting the highest practicable physical, mental, and psychological well-being of its residents. During an interview, the Maintenance Supervisor revealed that the fire alarm system was undergoing routine inspections but was not functioning properly. Despite following normal procedures and submitting documents for repairs, the work was not completed. The issue recurred, and the company responsible for repairs attempted to fix the motherboard, which was too old to be repaired or integrated with a new panel. Consequently, the fire alarm system failed to send signals to the doors to work properly, and the facility administration was in the process of obtaining estimates and bids for a new wireless fire alarm system. The Nursing Home Administrator confirmed that the building was old and had undergone an addition. Maintenance inspections were conducted weekly, monthly, and quarterly. The alarm company tried to fix the outdated motherboard but failed, and attempts to integrate a new panel were unsuccessful. The facility's Policies and Procedures for Utilities Management and Safety Management Plans emphasized the importance of providing a safe and comfortable environment for patients, staff, and visitors. However, the failure to maintain a functional fire alarm system compromised the safety and well-being of the facility's residents, staff, and visitors.
Failure to Ensure Dignity for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to ensure dignity for a resident with an indwelling catheter, as evidenced by the resident's urinary drainage collection bag not being fully covered by a dignity bag. On multiple occasions, the resident was observed with an uncovered drainage bag, both in his room and outside his room while being transported to therapy. The resident expressed a preference for a leg bag for more freedom and privacy, but the facility's protocol requires the use of a dignity bag to cover the drainage bag when the resident is out of bed. Staff members acknowledged the requirement but failed to consistently implement it, resulting in the resident's dignity being compromised. The resident, who was admitted with a diagnosis of Benign Prostatic Hyperplasia (BPH) and had no cognitive impairment, required various levels of assistance for daily activities. Despite the care plan and physician orders specifying the need for the drainage bag to be covered, staff members did not adhere to this protocol. The facility's policy on resident privacy and dignity, which mandates that all care procedures be performed with maximum privacy, was not followed in this instance, leading to the observed deficiency.
Failure to Transmit MDS Data Within Required Timeframe
Penalty
Summary
The facility failed to electronically transmit the Discharge-Return Anticipated Minimum Data Set (MDS) to the Centers for Medicare and Medicaid Services (CMS) within the required 14-day period for one resident who was discharged to a short-term general hospital. Specifically, the clinical records for the resident revealed that the Discharge Return Anticipated MDS, dated 12/04/2023, was not transmitted within the mandated timeframe. Instead, the MDS was transmitted on 03/14/2024, well beyond the 14-day requirement. An interview with the Regional MDS Coordinator on 03/15/2024 confirmed that the assessment was completed but not transmitted on time due to an oversight by the facility's MDS Coordinator. The facility's policy and procedures for the Resident Assessment Instrument (RAI) and the Interdisciplinary Care Planning Process, which were reviewed on 02/22/2024, mandate that completed RAI data must be transmitted to the state within regulatory timeframes. This failure to adhere to the policy resulted in the deficiency noted in the report.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in their care plans. Resident #86 was admitted with a care plan indicating a risk for nutrition and hydration issues due to missing or broken teeth. However, the MDS did not reflect the resident's use of dentures, which were received on 01/25/2024. The resident later reported issues with the dentures, but this was not documented in the MDS, and the MDS Coordinator admitted to not marking dentures because the resident did not inform her about wearing them. Resident #29, who had a diagnosis including pneumonia due to Coronavirus, bipolar disorder, and schizophrenia, was noted in the care plan to be able to smoke independently. However, the MDS inaccurately indicated that the resident did not use tobacco. The resident's smoking habits and preferences were documented in other records, but this information was not accurately reflected in the MDS. The MDS Coordinator acknowledged the error and stated that her assistant was responsible for the incorrect coding. Resident #166, diagnosed with emphysema, was observed using oxygen therapy, which was ordered at a rate of three liters per minute. Despite this, the MDS did not code the use of oxygen therapy in Section O for Special Treatments. The MDS Coordinator confirmed that the oxygen therapy was documented in the Medication Administration Records (MAR) and visually assessed but was not included in the MDS. The coordinator did not know why this was missed and stated that she would make the correction.
Failure to Follow Fall Precaution Orders
Penalty
Summary
The facility failed to provide a safe environment by not following physician orders to place bilateral floor mats for four residents who were at risk for falls. Observations revealed that the floor mats were either not in place or improperly positioned, despite physician orders and care plans indicating their necessity. For instance, Resident #36 was observed on multiple occasions with one or both floor mats folded and leaning against the wall, contrary to the physician's order for bilateral floor mats when in bed. Interviews with staff confirmed that the mats were removed for various reasons, such as serving meals, but were not promptly replaced as required. Resident #71, who had a recent fall resulting in a shoulder fracture, was also observed without the required bilateral floor mats on several occasions. Staff interviews revealed a lack of awareness and inconsistency in ensuring the mats were in place, with some staff members unaware of the current location of the mats. The treatment administration record indicated that the order for bilateral floor mats was signed off every shift, yet the mats were not observed in place during multiple checks. Similarly, Resident #23 and Resident #171 were found without the necessary floor mats in place. Resident #23's floor mat was observed folded and leaning against the wall, and staff admitted to removing it for care activities but failing to replace it. Resident #171 was observed with only one floor mat in place, and the other mat was either folded or missing. Staff interviews highlighted a pattern of removing mats for care or cleaning and not promptly replacing them, despite clear orders and care plans requiring their use to prevent falls and injuries.
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What surveyors actually found near you
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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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Pines Nursing Home | 0.1 mi | ★★★★★ | 0 | 0 |
| Biscayne Health And Rehabilitation Center | 0.7 mi | ★★★★★ | 9 | 0 |
| North Dade Nursing And Rehabilitation Center | 0.7 mi | ★★★★★ | 9 | 0 |
| Fountain Manor Health & Rehabilitation Center | 1 mi | ★★★★★ | 1 | 0 |
| Pinecrest Center For Rehabilitation And Healing | 1.2 mi | ★★★★★ | 0 | 0 |
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