Villa Maria Nursing Center: Resident Elopement - FL
The resident was wearing a pink elopement band on his ankle. His daughter had brought him downstairs to the patio earlier that day and left him with the activities staff. When the activities worker couldn't find him, she announced a Code Pink. Staff searched the stairs, the hallways, around the building. The nurse manager called the administrator and the risk manager. The social worker called the police.
The security officer, who had worked at the facility for more than three months, later told inspectors what happened at the gate. A medical transport van was waiting to leave. Someone else was trying to come in. He was looking at that person's ID when the resident walked out. "I only saw the person walking out when they showed me the video," he said.
Video footage reviewed by the administrator and the engineering director showed the resident in conversation with a visitor near the gate, telling the visitor to stop following him. Then he was gone.
The Director of Nursing got the call while driving to the facility. She took a nursing assistant and went looking. By then, police had already found the resident and transported him to a local emergency room. The DON drove to the hospital. He was alert, stable, and responsive. She called his daughter.
The daughter wanted him brought back immediately. The DON told her no, that she would need to speak with the hospital. The daughter eventually went herself and brought him back. He was placed on one-to-one supervision, then transitioned to 30-minute rounding checks.
The ADON told inspectors she hadn't known the resident was at elopement risk. A new procedure was put in place: one gate opens at a time, guards keep eyes on who is leaving, and nurses document which residents are at risk in their assignment sheets.
CMS rated the lapse Immediate Jeopardy.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Villa Maria Nursing Center from 2025-09-05 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
VILLA MARIA NURSING CENTER in NORTH MIAMI, FL was cited for violations during a health inspection on September 5, 2025.
The resident was wearing a pink elopement band on his ankle.
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.