Villa Maria Nursing Center
VILLA MARIA NURSING CENTER in NORTH MIAMI, FL — inspection on September 5, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
and did a search.
Our new procedure: In-service the security at the gate, that when one gate opens, the other one is closed.
Discussed more about elopement.
There should always be someone there when the patients are down for activities.
Ensured that the assignments for the nurses and the CNAs document who are at risk for elopement.On 9/05/2025 at 11:52 AM, the Administrator stated, I am two minutes from my house and get a call from the ADON that one of the residents was missing and they couldn't find him.
Code pink was called, and I turned around and came back.
The Engineering Director and I looked at the video footage. We saw the resident and how he was able to leave. He was in communication with one of the visitors and he was telling him to stop following him. We got a call from the police saying that he was found.
The facility communicated with the daughter and that he had been found.
After communicating with the daughter, she said that she didn't want anything to be done at the hospital and wanted him to come back to the facility. We also communicated with the medical director.
The daughter went to the hospital and brought him back to the facility. He was put on 1:1 and then transitioned to 30-minute rounding.
The Risk Manager was in-servicing the staff about the elopement and had a long conversation with the guard at the gate.
The next day formal in-services started, and we started a root cause and analysis. We looked at film and came up with solutions. We have a new process: One gate at time to be opened and the guards must put their eyes on who is leaving.
When he left there was no one in the lobby to see him leave.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/05/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Maria Nursing Center
1050 NE 125th Street North Miami, FL 33161
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
the residents was missing and they couldn't find him.
Code pink was called, and I turned around and came back.
The Engineering Director and I looked at the video footage. We saw the resident and how he was able to leave. He was in communication with one of the visitors and he was telling him to stop following him. We got a call from the police saying that he was found.
The facility communicated with the daughter and that he had been found.
After communicating with the daughter, she said that she didn't want anything to be done at the hospital and wanted him to come back to the facility. We also communicated with the medical director.
The daughter went to the hospital and brought him back to the facility. He was put on 1:1 and then transitioned to 30-minute rounding.
The Risk Manager was in-servicing the staff about the elopement and had a long conversation with the guard at the gate. We have a new process: One gate at time to be opened and the guards must put their eyes on who is leaving. We reviewed the books for people at elopement risk, but we also added the wanders.
When he left there was no one in the lobby to see him leave.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/05/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Maria Nursing Center
1050 NE 125th Street North Miami, FL 33161
SUMMARY STATEMENT OF DEFICIENCIES
him at the door.
Any patient I see, I would check my book and call the nurse to come and get them. My responsibilities are to answer the phones and assist family members coming into the building.On 9/05/2025 at 9:38 AM, the Registered Nurse, Assistant Director of Nursing (ADON) stated, I work 8:00 AM to 4:00 PM. On 8/4 that day the daughter took the patient downstairs to the patio.
She left him with activities. We didn't really know if he was in activities.
After the activities lady said she couldn't find the patient and announced code pink. We were looking for the patient in the stairs, around the building, everywhere.
After we couldn't find him, the Social Worker called the police. We continued looking for the patient, called the Administrator and the Risk Manager.
They found out the police found the patient and took him to [local hospital].
Pink band was on the patient. If the patient takes it off, we put it around the ankle.
His was on the ankle. On 9/05/2025 at 11:52 AM, the Administrator stated, I am two minutes from my house and get a call from the ADON that one of the residents was missing and they couldn't find him.
Code pink was called, and I turned around and came back.
The Engineering Director and I looked at the video footage. We saw the resident and how he was able to leave. He was in communication with one of the visitors and he was telling him to stop following him. We got a call from the police saying that he was found.
The facility communicated with the daughter and that he had been found.
After communicating with the daughter, she said that she didn't want anything to be done at the hospital and wanted him to come back to the facility. We also communicated with the medical director.
The daughter went to the hospital and brought him back to the facility. He was put on 1:1 and then transitioned to 30-minute rounding.
The next day formal in-services started, and we started a root cause and analysis. We looked at film and came up with solutions. We have a new process: One gate at time to be opened and the guards must put their eyes on who is leaving.
When he left there was no one in the lobby to see him leave.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/05/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Maria Nursing Center
1050 NE 125th Street North Miami, FL 33161
SUMMARY STATEMENT OF DEFICIENCIES
Based on record review and interviews, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action related to adequate supervision resulting in repeated deficient practice.
The facility's history includes deficient practice for failing to supervise residents resulting in possible accidents.
The facility was cited for Free of Accident Hazards, Supervision, Devices, Administration and Quality Assurance and Assessment on July 31, 2025. On 8/04/2025, the facility was negligent and failed to provide adequate supervision and effective services to prevent the elopement of one (Resident #1) out of three sampled residents with exit seeking behaviors, resulting in Resident #1 eloping from the facility at 4:24 PM, through an electronic gate in the front of the facility on foot undetected.
These repeated deficient practices have the potential to affect any of the 191 residents residing in the facility.The findings included:
Record review of the facility's Quality Assurance Performance Improvement (QAPI) Program Policy and Procedure (implemented December 2004) documented the following: Policy-This facility shall develop, implement and maintain an effective, comprehensive, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents; QAPI purpose is a type of quality management program which takes a systematic, interdisciplinary, comprehensive and data-driven approach to maintaining and improving safety and quality.
Guidelines for Governance and Leadership: 1) The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan; 2) The QAA Committee shall be interdisciplinary and shall: b) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program; 3) b) Policies and procedures for feedback, data collection systems and monitoring, c) Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies.
Key components of this process include, but are not limited to, the following: i.) Tracking and measuring performance, iii.) Identifying and prioritizing quality deficiencies, iv.) Systematically analyzing underlying causes of systemic quality deficiencies and v.) Developing and implementing corrective action or performance improvement activities.
Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 6/17/25, 7/15/25 and 8/19/25 documented the facility had a QAA Committee meeting monthly.
Attendees included: Executive Director, DON, Medical Director, Director of Social Services, Director of Activities, Dietitian, MDS Coordinator, Director of Case Management, Director of Housekeeping/Laundry Services, Risk Manager, Infection Control, Director of Health Information Management, Fiscal Services, Pharmacist, Data Analyst, Laboratories and Community Liaison.Interview with the Director of Nursing/QAA on 9/05/25 at 2:27 PM.
She stated, The QAA Committee meet monthly and we meet on the third Tuesday of the month.
The committee members consist of the Administrator, DON, Medical Director and Department Heads.
The purpose of the QAA committee is to bring forth any concerns that we may have and that we may need to address patient concerns and quality of care.
Facility ID: