Cycle 1
Health 2025-03-26 · Fire 2025-03-26
13 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Miami, FL
Miami Shores Nursing And Rehab Center
3-star overall rating with 3-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
9380 Nw 7th Avenue, Miami, FL
(305) 759-8711
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.22
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.38
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.43
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.03
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.59
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.97
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.11
CMS adjusted RN staffing hours
Adjusted total hours
3.67
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,608
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.32% · Performance 24.11% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.97% · Performance 8.87% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.59
Performance 36.73% · Measure score 6.59 · Achievement 6.59 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.32
Baseline 3.82 hours · Performance 3.45 hours · Measure score 1.32 · Achievement 1.32 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.06% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 124 · Observed rate 15.32% · Lower 95% interval 8.43% |
| Discharge to community | 33.7% |
50.57%
16.9 pts worse
|
Worse than the National Rate · Eligible stays 104 · Observed rate 21.15% · Lower 95% interval 25.46% |
| Medicare spending per beneficiary | 1.5 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 99.43% |
95.27%
4.2 pts better
|
Numerator 173 · Denominator 174 |
| Falls with major injury | 1.15% |
0.77%
0.4 pts worse
|
Numerator 2 · Denominator 174 |
| Discharge self-care score | 72.29% |
53.69%
18.6 pts better
|
Numerator 60 · Denominator 83 |
| Discharge mobility score | 55.42% |
50.94%
4.5 pts better
|
Numerator 46 · Denominator 83 |
| Pressure ulcers or injuries, new or worsened | 3.45% |
2.29%
1.2 pts worse
|
Numerator 6 · Denominator 174 · Adjusted rate 2.09% |
| Healthcare-associated infections requiring hospitalization | 8.87% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 13.25% · Lower 95% interval 5.21% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 141 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 57.83% |
56.45%
1.4 pts better
|
Numerator 48 · Denominator 83 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 86 · Denominator 86 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 25.3% |
25.2%
0.1 pts better
|
Numerator 21 · Denominator 83 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.8 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.2
0.8 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.5 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
2.6%
1.3 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 2.6% · Q4 1.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.3% |
3.7%
13.6 pts worse
|
11.4%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 23.9% · Q3 10.4% · Q4 13.2% · 4Q avg 17.3% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
5.9%
0.1 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 8.2% · Q3 5.6% · Q4 5.6% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.0% |
15.7%
2.3 pts worse
|
19.6%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 14.3% · Q3 16.2% · Q4 21.9% · 4Q avg 18.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.8% |
9.8%
2 pts worse
|
16.7%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 15.5% · Q3 9.6% · Q4 5.7% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.6% |
11.7%
6.1 pts better
|
16.3%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q3 0.0% · Q4 3.5% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.5% |
9.8%
0.3 pts better
|
14.9%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 18.6% · Q3 10.2% · Q4 5.1% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
0.8%
0.1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 1.3% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 0.0% |
12.5%
12.5 pts better
|
19.8%
19.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
5.1%
2.7 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 8.9% · Q3 3.9% · Q4 10.2% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
94.3%
5.4 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.5% |
9.3%
2.8 pts better
|
12.0%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.5% · Observed 7.9% · Expected 13.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.3% |
1.5%
5.8 pts worse
|
1.6%
5.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 8.1% · Q3 3.7% · Q4 3.8% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.0% |
94.7%
3.3 pts better
|
79.7%
18.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 37.2% |
26.2%
11 pts worse
|
23.9%
13.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 37.2% · Observed 44.4% · Expected 28.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-19 · Fire 2023-10-19
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-11-04 · Fire 2022-11-04
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-01
D · Potential for more than minimal harm
2025-03-26
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-05-01
D · Potential for more than minimal harm
2025-03-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-01
D · Potential for more than minimal harm
2025-03-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-01
D · Potential for more than minimal harm
2023-10-19
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-12-17
D · Potential for more than minimal harm
2023-10-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-10-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-10-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-10-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-19
D · Potential for more than minimal harm
2022-11-04
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-01-27
D · Potential for more than minimal harm
2022-11-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-04
D · Potential for more than minimal harm
2022-11-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-24
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-07-24
E · Potential for more than minimal harm
2025-03-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-26
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-26
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-26
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-26
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-03-26
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-04-26
D · Potential for more than minimal harm
2023-10-19
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-10-19
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-10-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-11-19
D · Potential for more than minimal harm
2023-10-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-19
D · Potential for more than minimal harm
2022-11-04
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-12-04
D · Potential for more than minimal harm
2022-11-04
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-12-04
D · Potential for more than minimal harm
2022-11-04
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-12-04
D · Potential for more than minimal harm
2022-11-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-04
D · Potential for more than minimal harm
2022-11-04
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-12-04
D · Potential for more than minimal harm
2022-11-04
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-12-04
Penalties and ownership
What sits behind the stars
Ownership
Hernando, Jorge
5% Or Greater Direct Ownership Interest · Individual
Antonacci, Nick
5% Or Greater Direct Ownership Interest · Individual
Hernando, Gladys
5% Or Greater Direct Ownership Interest · Individual
Antonacci, Nick
Limited Partnership Interest · Individual
Antonacci, Nick
Corporate Director · Individual
Carrasco, Marco
Operational/Managerial Control · Individual
Hernando, Gladys
Corporate Director · Individual
Hernando, Jorge
General Partnership Interest · Individual
Hernando, Jorge
Limited Partnership Interest · Individual
Hernando, Jorge
Corporate Director · Individual
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