Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Waterford Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Protect Resident Information and Privacy: Surveyors observed multiple unattended medication carts and a nursing station with open computer screens and unsecured paperwork showing resident information. Staff acknowledged that screens should be closed and documents covered or turned over when unattended. Surveyors also observed an RN administering medications to a cognitively intact resident with the room door open, while the DON and nursing supervisors stated that doors or curtains are to be closed during medication administration.
Unsafe utility rooms and unsecured medication supplies were observed during survey. An unlocked soiled utility room with biohazardous materials, unlocked clean utility rooms that could be locked from the inside and had no call light, and an unlocked sprinkler room containing hazardous equipment were found without staff present. In addition, an RN left a medication cart unlocked with a lancet on top and later left a lancet at a resident's bedside; the resident had DM2, no cognitive impairment, and an order for blood sugar checks twice daily.
A resident with dementia and a PEG tube had enteral feeding running with the pump uncovered while seated in a hallway and later in the dining area during activities. Staff were unsure about covering the tube feeding, the RN supervisor stated it should be covered when the resident was not in the room, and the DON stated nurses are not permitted to administer enteral feedings in common areas. The facility’s Residents Rights policy states residents have the right to a dignified existence and self-determination.
Facility failed to properly label and secure medications and supplies on medication carts. An RN removed a pill from a stock bottle with an illegible expiration/open date, left a syringe with normal saline on top of a medication cart while entering a resident’s room, and another RN left a medication cart unlocked with a lancet on top during a blood glucose check. The DON stated meds and supplies are to be secured in locked carts when unattended, and facility policy required legible labels and locked carts when out of the nurse’s view.
QAA committee failed to identify and address repeated deficiencies involving medication storage and labeling, accident hazards, and resident privacy. The facility had prior citations for Label/Store Drugs and Biologicals, Personal Privacy/Confidentiality of Records, and Free of Accident Hazards/Supervision/Devices, and the report states the repeated deficient practice could affect any of the 206 residents. The QAPI policy required an interdisciplinary QAA committee to meet at least quarterly and develop plans of action, and the Administrator stated the committee met monthly with the Administrator, DON, Medical Director, department heads, and some line staff.
Walk-in freezer curtains were observed with ice accumulation during two kitchen tours, despite the facility’s policy requiring essential equipment to be kept in safe operating condition. The Dietary Director stated the ice should not be there, attempted to scrape it off, and later noted the ice was still present and that the freezer latch might not be working right.
A facility failed to ensure the safety of a resident with orders for bilateral floor mats, as only one mat was often in place, contrary to physician's orders. Additionally, three out of four biohazard rooms were found unlocked, allowing staff to enter without a code or key, violating the facility's policy for biohazard waste management.
A privacy breach occurred when a medication cart was left unattended with residents' personal health information visible on the electronic medication administration screen. A RN admitted to leaving the screen open while entering a resident's room, contrary to the facility's HIPAA policy requiring protection of personal health information.
A facility failed to accurately code an MDS assessment for a resident discharged home, incorrectly documenting the discharge as to a hospital. The resident, with a history of cerebral infarction and other conditions, was admitted for rehabilitation and intended to return home. Record reviews and staff interviews confirmed the error, highlighting a lapse in following the facility's MDS documentation policy.
A resident with severe cognitive impairment had medications left unsecured on their overbed table, contrary to facility policy. The CNA admitted to leaving the items out, and the LPN stated that medications are usually stored at the nurses' station or in a bedside drawer. The DON confirmed the oversight after reviewing evidence.
Failure to Protect Resident Information and Privacy
Penalty
Summary
The facility failed to keep residents’ personal and medical records private and confidential when unattended computer screens and unsecured paperwork with resident information were left visible in multiple locations. Survey observations identified an open computer screen on the second-floor medication cart #2 with resident information visible, visible demographic paperwork at the first-floor nursing station, unsecured paperwork on the second-floor medication cart #1, and open computer screens and paperwork with resident information visible on the third-floor medication carts #1 and #2. Staff members acknowledged that computer screens should be closed and paperwork with resident information should be turned over, covered, shredded, or otherwise protected when unattended. The facility also failed to provide privacy for one resident during medication administration. During an observation, an RN was seen administering medications to the resident in the room with the door open. Record review showed the resident was admitted and readmitted with a diagnosis of cerebral infarction, was cognitively intact per the quarterly MDS, and had a care plan noting a self-care deficit with interventions including allowing the resident to perform tasks at their own pace. The DON and nursing supervisors stated that computer screens are to be closed and that doors or curtains are to be closed during medication administration to provide privacy.
Unsafe Utility Rooms and Unsecured Medication Supplies
Penalty
Summary
The facility failed to keep resident areas free of accident hazards and did not provide adequate supervision during several observations. On the third floor, an unlocked Soiled Utility Room contained biohazardous materials, and an unlocked Clean Utility Room was observed even though it could be locked from the inside and had no call light; there was no staff present in either room. Similar conditions were observed on the first floor, where an unlocked Clean Utility Room that could be locked from the inside had no call light and no staff inside. The first-floor Sprinkler Room was also observed unlocked with no staff present, and it was later toured with the Maintenance Director, Administrator, and Regional Director of Clinical Services, who confirmed it could be locked from the inside and contained materials and equipment potentially hazardous to residents. During medication administration, Staff G, RN left the third-floor medication cart unlocked with a lancet on top while entering a resident's room, and later left a lancet at the bedside of Resident #142. Resident #142 had a diagnosis of Type 2 Diabetes Mellitus, no cognitive impairment on the most recent MDS, and an order to obtain blood sugar twice daily. The resident's care plan included self-care deficit interventions. The DON stated nurses are to secure all medications and supplies in medication carts and lock the carts when unattended for resident safety. The facility policy stated the resident environment should remain as free of accident hazards as possible and that each resident should receive adequate supervision and assistive devices to prevent accidents.
PEG Feeding Pump Left Visible in Common Areas
Penalty
Summary
The facility did not honor Resident #77’s right to a dignified existence when the resident’s PEG tube feeding pump was left overtly visible while enteral feeding was in progress in common areas. On 03/02/2026 at 11:48 AM, Resident #77 was observed in the hallway seated in a wheelchair with enteral feeding running via PEG and the system uncovered. On 03/03/2026 at 1:45 PM, the resident was again observed in the dining area seated in a wheelchair during activities with enteral feeding in progress via PEG and not covered. Resident #77’s records showed the resident was re-admitted with a diagnosis including dementia, had severe cognitive impairment, was dependent on activities of daily living, and had a feeding tube on the quarterly MDS dated 02/06/2026. The physician’s orders included Enhanced Barrier Precautions related to the PEG tube every shift. During interviews, a CNA stated she did not know if the tube feeding should be covered and would ask the nurse, while the RN supervisor stated the tube feeding for Resident #77 should be covered while the resident was not in the room. The DON stated nurses are not permitted to administer enteral feedings in common areas. The facility policy on Residents Rights stated residents have the right to a dignified existence, self-determination, and communication.
Improper Medication Storage and Illegible Labeling on Medication Carts
Penalty
Summary
Facility failed to properly store and label medications and biologicals on two medication carts. During medication administration on 03/05/2026, Staff H, RN removed a pill from a bottle for a resident, but the expiration date and open date on the stock medication bottle were not legible. Staff H was unable to read the expiration date, and the 1st floor supervisor RN was notified and brought a new bottle to the cart. During the same observation, Staff H entered the resident’s room with medication and left a syringe with normal saline on top of the first-floor medication cart #1. During a blood glucose check observation on 03/03/2026, Staff G, RN was observed entering a resident’s room and leaving the third-floor medication cart #1 unlocked with a lancet on top of the cart. When the nurse returned, staff acknowledged that medications and supplies are to be locked in the cart. The DON also stated that nurses are to secure all medications and supplies in medication carts and lock the carts when unattended. The facility’s policy required medications and biologicals to be labeled in accordance with current state, federal regulations and accepted pharmaceutical principles, with medication labels legible at all times, and stated that the medication cart must be locked when out of the nurse’s view.
QAA Committee Failed to Address Repeated Quality Deficiencies
Penalty
Summary
The facility's QAA committee failed to identify quality concerns and implement effective plans of action related to repeated deficient practices involving medication storage and labeling during medication administration, accident hazards, and resident privacy. The facility had been cited in 2024 for Label/Store Drugs and Biologicals, Personal Privacy/Confidentiality of Records, and Free of Accident Hazards/Supervision/Devices, and the report states this repeated deficient practice had the potential to affect any of the 206 residents in the facility. The facility's QAPI policy required an interdisciplinary QAA committee to meet at least quarterly and develop and implement plans of action to correct identified quality deficiencies. Review of QAPI committee sign-in sheets showed quarterly meetings with the Administrator, Medical Director, DON, and other department heads. During interview, the Administrator/QAA stated the committee actually met monthly and included the Administrator, DON, Medical Director, department heads, and some line staff, and that the purpose was to review areas needing improvement and evaluate performance using a proactive approach.
Walk-in freezer had ice accumulation on curtains
Penalty
Summary
The facility failed to ensure the walk-in freezer was working properly. During the initial kitchen tour with the Dietary Director, the freezer curtains were observed to contain ice, and photographic evidence was submitted. The facility’s Physical Environment Policy and Procedure states that all essential mechanical and electrical equipment will be maintained in safe operating condition, and the Freezer Defrost and Maintenance Policy states that dietary staff are to conduct routine daily observation of freezer interiors and submit a work order if unusual or persistent ice accumulation is observed. On the following day, the walk-in freezer was observed again with ice still present on the curtains, with photographic evidence submitted. During interview, the Dietary Director stated that the ice should not be there and attempted to scrape and remove it during the first observation. On the second observation, he stated there was still ice on the curtains, though not as much as the day before, and suggested the latch on the freezer might not be working right.
Deficiencies in Resident Safety and Biohazard Room Security
Penalty
Summary
The facility failed to ensure the safety of a vulnerable resident, identified as Resident #54, who had orders for bilateral floor mats to prevent falls. Observations revealed that on multiple occasions, only one floor mat was in place while the resident was in bed, contrary to the physician's orders. Interviews with staff, including an LPN and a CNA, confirmed that the resident was supposed to have two floor mats, and they were responsible for ensuring the mats were in place during rounds. The resident's medical records indicated a history of falls and a care plan that included the use of bilateral floor mats for safety. Despite these measures, the facility did not consistently implement the necessary interventions to reduce the risk of falls for Resident #54. Additionally, the facility failed to maintain the security of biohazard rooms, as three out of four soiled utility rooms were found unlocked. Staff members, including an RN and a CNA, were observed entering these rooms without using a code or key, which is against the facility's policy for biohazard waste management. The Director of Nursing confirmed that the biohazard rooms are supposed to be locked automatically to ensure resident safety and infection control. A tour of the facility revealed that the doors to these rooms were not functioning as intended, allowing unauthorized access.
Privacy Breach of Residents' Health Information
Penalty
Summary
The facility failed to maintain the privacy of residents' personal and medical records, as observed on one of the eight medication carts. During an observation on the third floor, an unattended medication cart was found with residents' personal health information visible on the electronic medication administration screen. This incident involved Staff E, a Registered Nurse (RN), who left the computer screen open while quickly entering a resident's room. Upon inquiry by the surveyor, Staff E acknowledged the oversight and stated that the screen should have been closed when away from the medication cart. The facility's policy on HIPAA, implemented on 11/27/2019, mandates that all employees comply with procedures to protect residents' personal identifiable health information. The policy also specifies that sanctions will be applied against employees who fail to adhere to these procedures. At the time of the survey, there were 201 residents residing in the facility.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code a Minimum Data Set (MDS) assessment for a resident who was discharged from the facility. The resident, who had a medical history of cerebral infarction, atrial fibrillation, hypertension, and osteoarthritis, was admitted for short-term rehabilitation and was intended to return to the community. However, the MDS assessment incorrectly documented the resident as being discharged to an acute hospital, while the resident was actually discharged home with home health services. The error was identified through a review of various records, including the Demographic Face Sheet, Physician's Order Sheet, Discharge Care Plan, and IDT Discharge Progress Note, all of which confirmed the resident's discharge to their home. Interviews with the Social Services Director, MDS Coordinator, and Director of Nursing corroborated the documentation error, acknowledging that the MDS was incorrect in stating the resident was discharged to the hospital. This discrepancy highlights a failure in the facility's adherence to its policy and procedure for ensuring accurate MDS documentation.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe storage of medications for one resident, as observed during a survey. Medications, including two ointments, one medicated powder, and one cream, were found on the overbed table in the resident's room. The resident, who was asleep at the time of the initial observation, has a severe cognitive impairment with a Brief Interview for Mental Status Score of four out of fifteen. The resident requires substantial to total staff assistance with activities of daily living due to a self-care deficit and is at risk for complications and decline. Interviews with staff revealed that the Certified Nursing Assistant (CNA) assigned to the resident admitted to leaving the medicated items on the overbed table after use. The Licensed Practical Nurse (LPN) mentioned that barrier creams are typically stored at the nurses' station, and any items brought by the family are stored in the bedside drawer. The Director of Nursing (DON) confirmed the CNA's admission after reviewing a photo of the items left on the overbed table. The facility's policy requires all medications and biologicals to be labeled and stored according to state and federal regulations, which was not adhered to in this instance.
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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 Hialeah Gardens
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Susanna Wesley Health Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Palmetto Care Center And Rehab | 1.4 mi | ★★★★★ | 8 | 0 |
| Terrace Of Hialeah, The | 3.2 mi | ★★★★★ | 7 | 0 |
| Miami Springs Nursing And Rehabilitation Center | 4.4 mi | ★★★★★ | 0 | 0 |
| Hialeah Shores Nursing And Rehab Center | 5.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.