Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 West Skilled Nursing Facility during CMS and state inspections, most recent first.
A resident admitted with COPD and pneumonia-related treatment orders received multiple respiratory interventions, including nebulized meds, oxygen saturation monitoring, antibiotics, steroids, and a pulmonology consult, but the baseline care plan was not completed within the required timeframe and did not include interim documentation of the resident’s respiratory treatments or goals until after surveyor inquiry.
Repeated F655 citation for failure to develop a baseline care plan. A prior survey cited the facility for not developing a baseline care plan for oxygen use for one resident, and the current survey again found that a resident's baseline care plan for respiratory care was not developed. During a QAPI review, the DON and Administrator described a monthly QAA committee with multidisciplinary attendance, ongoing audits, and current improvement projects focused on hospital transfers, nutrition services, pressure ulcer prevention, and fall reduction.
The facility failed to develop a baseline care plan for a resident receiving oxygen therapy. The resident was observed receiving oxygen at a rate higher than the physician's order, and the baseline care plan did not include the oxygen order. The resident had a history of acute respiratory failure, CHF exacerbation, COPD exacerbation, and a recent pacemaker insertion.
The facility failed to follow the urinary catheter care plan for a resident with urinary retention due to an enlarged prostate. Observations revealed the drainage bag was not maintained below the bladder level and was not covered with a privacy bag, contrary to the care plan instructions.
The facility failed to follow its catheter care policy for a resident with an indwelling urinary catheter. The drainage bag was not maintained below the bladder level and was not placed in a privacy bag as required. These deficiencies were observed during multiple instances, including when the resident was in his room, being transported, and during therapy sessions.
A resident with a history of acute respiratory failure and other conditions was found receiving oxygen at 4 liters per minute instead of the physician-ordered 2 liters per minute. The discrepancy was not initially included in the baseline care plan, leading to a deficiency.
A facility failed to follow infection control standards during blood glucose monitoring for a resident with Type II Diabetes Mellitus. An LPN took the entire blood glucose monitoring kit into the resident's room, contrary to standard procedures. The DON confirmed that the facility's policy does not explicitly address this issue, although nurses are typically trained to avoid contamination.
Failure to Complete Baseline Care Plan for Respiratory Needs
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission that addressed Resident #49’s respiratory needs. Resident #49 was admitted on 09/04/2025 with diagnoses including Encounter for other specified aftercare and COPD, and the admission MDS was in progress. Physician orders dated between 09/04/2025 and 09/09/2025 showed multiple active respiratory treatments, including Budesonide nebulizer twice daily, Formoterol Tartrate nebulizer twice daily, Ipratropium-Albuterol nebulizer every six hours, oxygen saturation checks, and later orders for a pulmonology consultation for pneumonia, Prednisone, and Cefuroxime. Progress notes from 09/07/2025 and 09/08/2025 documented treatment for pneumonia and COPD. On 09/10/2025, the MDS RN confirmed that although the ARD was set for 09/10/2025 and baseline care plan initiation was scheduled for that day, the resident had already been receiving multiple respiratory interventions since admission and the baseline care plan had not been completed. The MDS RN acknowledged that the plan lacked interim documentation outlining essential respiratory treatments or goals. After surveyor inquiry, the DON hand-delivered a newly created baseline care plan, confirming it had not been completed within the required time frame and was created in response to the surveyor’s involvement.
Repeated Failure to Develop Baseline Care Plan
Penalty
Summary
The facility failed to implement effective corrective actions after a previously cited deficiency for F655, Development of a Baseline Care Plan. During a prior recertification survey with an exit date of 05/15/2024, F655 was cited because the facility failed to develop a baseline care plan for oxygen use for one resident. On the current survey with an exit date of 09/11/2025, the same deficiency was cited again because the facility did not develop Resident #49's baseline care plan for respiratory care. On 09/11/2025 at 12:30 PM, a QAPI review was conducted with the DON and Administrator. The facility reported having a QAA Committee that meets monthly on the second Wednesday, with the most recent meeting on September 13, 2025, and sign-in sheets showed attendance by nursing, therapy, social services, dietary, and environmental services. The facility's QAPI policy dated February 14, 2025 was reviewed, and the committee described using data, teamwork, audits, staff feedback, and structured tools to prioritize projects and track progress. Current improvement plans focused on hospital transfers and nutrition services, with other top issues including pressure ulcer prevention and fall reduction.
Failure to Develop Baseline Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was receiving oxygen therapy. During an observational tour, the resident was found receiving oxygen via nasal cannula at a rate higher than the physician's order. The resident reported being on oxygen at 2 liters per minute, but the oxygen flow meter was set at 4 liters per minute. Subsequent observations showed the resident receiving oxygen at the correct rate, but the baseline care plan did not include information about the oxygen order. The resident had a history of acute respiratory failure, congestive heart failure exacerbation, chronic obstructive pulmonary disease exacerbation, and a recent pacemaker insertion. A review of the resident's electronic medical record revealed that the baseline care plan and summary did not include the physician's order for oxygen at 2 liters per minute. The Director of Nurses confirmed that the oxygen order was not included in the baseline care plan and summary or the interim care plan-admission. Although a comprehensive care plan was later provided, it was not part of the initial baseline care plan, leading to the deficiency in meeting the resident's immediate needs upon admission.
Failure to Follow Urinary Catheter Care Plan
Penalty
Summary
The facility failed to follow the urinary catheter care plan for a resident with urinary retention due to an enlarged prostate. During multiple observations, the resident's urinary catheter drainage bag was not maintained below the level of the bladder and was not covered with a privacy bag as required by the care plan. Specifically, the drainage bag was observed at the same level as the resident while he was sitting in a wheelchair, and later, the bag was placed at the head of the bed with the tubing on the bed, not inside the privacy bag. These observations were made during different times of the day, indicating a consistent failure to adhere to the care plan. The resident's electronic medical record confirmed the diagnosis and the physician's order for catheter care every shift. The care plan, dated 5/9/24, included specific interventions to ensure the drainage bag hangs below the bladder level and is covered when the resident is out of bed. Despite these instructions, the care plan was not followed, as evidenced by the observations. The Director of Nurses was interviewed regarding these observations, but the report does not include any corrective actions taken by the facility to address the deficiency.
Failure to Follow Catheter Care Policy
Penalty
Summary
The facility failed to follow its policy and procedure for catheter care for a resident with an indwelling urinary catheter. During multiple observations, the resident's urinary catheter drainage bag was not maintained below the level of the bladder and was not placed in a privacy bag as required by the care plan. Specifically, the drainage bag was observed at the same level as the resident while he was sitting in a wheelchair and was not covered by a privacy bag. Additionally, the catheter bag was found at the head of the resident's bed with the tubing on the bed, and the drainage bag was not inside the privacy bag. These observations were made during different times, including when the resident was in his room, being transported by therapy staff, and during therapy sessions. The resident, who was admitted with a diagnosis of urinary retention due to an enlarged prostate, had a physician's order for catheter care every shift. The care plan specifically instructed that the drainage bag should hang below the level of the bladder and be covered when the resident was out of bed. However, these instructions were not followed. The Director of Nurses confirmed the facility's policy, which emphasized the importance of keeping the drainage bag below the bladder to prevent urinary tract infections. The facility's failure to adhere to these guidelines was evident in the observations made during the survey.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure oxygen therapy was accurately administered as ordered by the physician for a resident. During an observation tour, the resident was found receiving oxygen via nasal cannula set at 4 liters per minute, despite the physician's order for 2 liters per minute. The resident, who had a history of acute respiratory failure, congestive heart failure exacerbation, and chronic obstructive pulmonary disease exacerbation, was not in distress at the time of observation. However, the discrepancy in oxygen administration was noted and documented with a photo. Subsequent observations showed the oxygen level was adjusted to 2 liters per minute, but the initial error was not addressed in the resident's baseline care plan or summary. Further review of the resident's electronic medical record revealed that the baseline care plan did not include the physician's order for oxygen at 2 liters per minute. The Director of Nurses confirmed that the oxygen order was missing from the baseline care plan and summary. The facility's policy on respiratory care, which mandates the provision and maintenance of respiratory equipment as ordered by a physician, was not followed in this instance. The comprehensive care plan was later updated to include the necessary interventions for the resident's respiratory status, but the initial oversight led to the deficiency.
Infection Control Breach During Blood Glucose Monitoring
Penalty
Summary
The facility failed to follow infection control standards and procedures during blood glucose monitoring for a resident. Specifically, a Licensed Practical Nurse (LPN) took the entire blood glucose monitoring machine kit, along with all the supplies enclosed, into the resident's room to perform blood glucose monitoring. The LPN applied a barrier on the overbed table, placed the blood glucose monitoring kit on the barrier, and proceeded with the blood glucose check. After completing the procedure, the LPN disposed of the supplies in a biohazard bag, cleaned the machine with disinfecting wipes, and washed hands before exiting the room. However, the LPN acknowledged that only the necessary supplies should have been taken into the room, and any leftover unused supplies should have been discarded upon leaving the room. The Director of Nursing (DON) confirmed that the facility's policy does not explicitly address whether the entire blood glucose monitoring kit can be taken into the resident's room. Typically, nurses place the machine and necessary supplies on a tray before entering the room. The facility's policy on blood glucose monitoring, revised in June 2018, outlines the steps for fingerstick sample collection but does not specify the handling of the entire kit. The resident involved had a clinical diagnosis of Type II Diabetes Mellitus and had orders for insulin administration per sliding scale before meals and at bedtime.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 319 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hialeah Gardens
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glades West Rehabilitation And Nursing C | 2.7 mi | ★★★★★ | 3 | 0 |
| Nspire Healthcare Miami Lakes | 4.6 mi | ★★★★★ | 7 | 0 |
| Palmetto Care Center And Rehab | 5.5 mi | ★★★★★ | 8 | 0 |
| Waterford Nursing And Rehabilitation Center | 6.4 mi | ★★★★★ | 8 | 0 |
| Susanna Wesley Health Center | 6.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Villa Maria West Skilled Nursing Facility.
100% money-back within 48 hours.
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.