Terrace of Hialeah: Quality Assurance Failures - FL
Inspectors cited the nursing home for deficiencies in its Quality Assurance Performance Improvement program, marking repeated violations that have the potential to affect all residents at the facility on West 28th Street.
The facility maintained a comprehensive QAPI policy implemented in November 2012 and revised as recently as November 2023. The policy outlined an "organized quality assessment and improvement process program" designed to measure, assess and improve performance across all facility operations.
According to the policy, the Quality Assurance Committee was supposed to establish "a planned, systemic organization wide approach" that included collaboration with interdisciplinary teams, direct care staff, residents and their representatives.
The policy required systematic data collection using appropriate statistical techniques, staff education on quality improvement methods, and continuous measurement of specific quality assurance indicators.
Monthly committee meetings were documented through sign-in sheets from March 29, April 29, and May 29, 2024. Attendees included the administrator, medical director, director of nursing, assistant director of nursing, infection control preventionist, dietary manager, clinical dietician, and directors of housekeeping, maintenance, therapy, human resources, admissions, business office, social services, and activities.
The MDS coordinator and consultant pharmacist also participated in the meetings, held on the last Friday of each month.
During a June 27 interview at 3:24 PM, the Director of Nursing and Administrator, who both serve on the Quality Assurance Committee, described the committee's structure and purpose. The director explained that the committee consisted of the medical director, administrator, director of nursing, assistant director of nursing, and all interdisciplinary team members.
The committee's stated focus was to identify problem issues in the facility, track and trend data, and identify opportunities for correction in facility systems. The process was supposed to include implementing interventions to correct issues and monitoring the effectiveness of those interventions through audits, staff feedback, town hall meetings, education and training, and observations of return demonstrations.
However, inspectors determined the facility failed to adequately implement these quality assurance requirements despite the detailed policies and regular meetings.
The violation represents a pattern of deficient practices at The Terrace of Hialeah. Inspectors noted the facility had been previously cited for similar quality assurance failures in 2023, indicating ongoing problems with the facility's oversight systems.
Federal regulations require nursing homes to maintain quality assurance programs that ensure proper governance, management, clinical care and support processes. Facilities must allocate adequate resources, including personnel and time, to support ongoing performance improvement activities.
The inspection found the facility's information systems and data management processes were insufficient to support the required performance improvement activities, despite the comprehensive policy framework.
The Quality Assurance Committee policy emphasized that activities should be collaborative and include input from direct care staff, other employees, residents and their representatives. The policy also required that data be systematically collected using appropriate statistical techniques and that information about processes and outcomes be maintained.
Staff were supposed to receive education on quality improvement approaches and methods, with training in reporting, assessing and improving processes that contribute to better resident outcomes.
The policy established expectations for committee functions, reporting methods and systems used to collect, manage and analyze data needed for quality improvement. It required identification of specific quality assurance measures to be monitored continuously.
Committee procedures were supposed to include analyzing and evaluating the effectiveness of the committee's contribution to improving quality across the facility.
The facility policy stated that adequate resources for assessing and improving governance, managerial, clinical and support processes must be allocated, including assignment of personnel with adequate time to participate in quality improvement activities.
Despite these comprehensive policy requirements and the documented monthly meetings with interdisciplinary participation, inspectors found the facility's actual implementation of quality assurance measures fell short of federal standards.
The citation for minimal harm or potential for actual harm affecting few residents suggests the quality assurance deficiencies had not yet resulted in serious injuries but created conditions that could lead to problems if left unaddressed.
The repeated nature of the violations, following similar citations in 2023, indicates systemic issues with the facility's ability to maintain effective quality oversight despite having policies and procedures in place.
The 231 residents at The Terrace of Hialeah remained potentially affected by the quality assurance program deficiencies, according to the inspection findings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terrace of Hialeah, The from 2024-06-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
TERRACE OF HIALEAH, THE in HIALEAH, FL was cited for violations during a health inspection on June 26, 2024.
The facility maintained a comprehensive QAPI policy implemented in November 2012 and revised as recently as November 2023.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.