4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Miami, FL
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
11215 Sw 84th Street, Miami, FL
(305) 271-2225
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
180
Certified beds
Average residents
173
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-03-18
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
RN hours / resident day
1.23
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.34
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.57
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.14
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.74
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.90
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.15
CMS adjusted RN staffing hours
Adjusted total hours
3.88
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Program rank
5,145
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9905
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 22.05% · Performance 23.08% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.73
Baseline 7.96% · Performance 6.12% · Measure score 5.73 · Achievement 5.73 · Improvement 5.70
Total nurse turnover
6.36
Performance 37.70% · Measure score 6.36 · Achievement 6.36 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.82
Baseline 3.96 hours · Performance 3.88 hours · Measure score 2.82 · Achievement 2.82 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.72% |
10.72%
2 pts worse
|
Worse than the National Rate · Eligible stays 407 · Observed rate 13.51% · Lower 95% interval 10.89% |
| Discharge to community | 69.06% |
50.57%
18.5 pts better
|
Better than the National Rate · Eligible stays 341 · Observed rate 62.76% · Lower 95% interval 63.88% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.54% |
95.27%
3.3 pts better
|
Numerator 270 · Denominator 274 |
| Falls with major injury | 0.36% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 274 |
| Discharge self-care score | 29.29% |
53.69%
24.4 pts worse
|
Numerator 58 · Denominator 198 |
| Discharge mobility score | 42.42% |
50.94%
8.5 pts worse
|
Numerator 84 · Denominator 198 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 274 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.12% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 223 · Observed rate 5.83% · Lower 95% interval 4.17% |
| Staff COVID-19 vaccination coverage | 2.17% |
8.2%
6 pts worse
|
Numerator 7 · Denominator 322 |
| Staff flu vaccination coverage | 91% |
42%
49 pts better
|
Numerator 283 · Denominator 311 |
| Discharge function score | 46.46% |
56.45%
10 pts worse
|
Numerator 92 · Denominator 198 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 65 · Denominator 65 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 151 · Denominator 151 |
| Resident COVID-19 vaccinations up to date | 6.2% |
25.2%
19 pts worse
|
Numerator 8 · Denominator 129 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.1 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.3 · 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 | 0.7% |
2.6%
1.9 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 1.3% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 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 who lose too much weight | 2.8% |
5.9%
3.1 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 5.2% · Q3 2.1% · Q4 3.0% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.1% |
15.7%
10.4 pts worse
|
19.6%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 29.4% · Q3 22.1% · Q4 20.8% · 4Q avg 26.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.1% |
9.8%
1.7 pts better
|
16.7%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 9.6% · Q3 9.1% · Q4 4.6% · 4Q avg 8.1% · 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 | 7.2% |
11.7%
4.5 pts better
|
16.3%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 10.0% · Q3 5.2% · Q4 7.1% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
9.8%
1.1 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 14.1% · Q3 8.2% · Q4 9.5% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.4%
0.8 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.6% · Q3 1.0% · Q4 0.5% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
0.8%
1.4 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 2.1% · Q3 0.0% · Q4 0.7% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.1% |
12.5%
7.4 pts better
|
19.8%
14.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 5.1% · Q3 5.4% · Q4 5.5% · 4Q avg 5.1% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
5.1%
2 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 5.0% · Q3 1.6% · Q4 1.7% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.1% |
9.3%
5.2 pts better
|
12.0%
7.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.1% · Observed 3.5% · Expected 9.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 1.1% · Q4 2.2% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.5% |
94.7%
4.8 pts better
|
79.7%
19.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.7% |
26.2%
0.5 pts worse
|
23.9%
2.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.7% · Observed 24.7% · Expected 22.0% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-11-07
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-07
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-07
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-06-09
Inspection history
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-03
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-03
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-03
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-03
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-06-10
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-10
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-06-10
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-06-10
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Corporate Officer · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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