Cycle 1
Health 2025-09-11 · Fire 2025-09-11
2 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Hialeah Gardens, FL
Villa Maria West Skilled Nursing Facility
5-star overall rating with 4-star inspections with 2 recent health deficiencies
8850 Nw 122 St, Hialeah Gardens, FL
(305) 351-7181
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
27
Certified beds
Average residents
24
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2009-02-09
CMS approved date
Coverage
Medicare
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.80
Registered nurse staffing
LPN hours / resident day
1.08
Licensed practical nurse staffing
Aide hours / resident day
2.54
Nurse aide staffing
Weekend hours
4.74
Weekend nurse staffing
RN turnover
21%
Annual RN turnover
Total nurse turnover
13%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.1% |
94.7%
1.4 pts better
|
79.7%
16.4 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-15 · Fire 2024-05-15
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-12-29 · Fire 2022-12-29
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-05-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-11
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-10-11
D · Potential for more than minimal harm
2025-09-11
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-10-11
D · Potential for more than minimal harm
2024-05-15
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-06-15
D · Potential for more than minimal harm
2024-05-15
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 2024-06-15
D · Potential for more than minimal harm
2024-05-15
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 2024-06-15
D · Potential for more than minimal harm
2024-05-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-15
D · Potential for more than minimal harm
2024-05-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-15
E · Potential for more than minimal harm
2022-12-29
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-01-26
E · Potential for more than minimal harm
2022-12-29
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-01-26
D · Potential for more than minimal harm
2022-12-29
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-01-26
Penalties and ownership
What sits behind the stars
Ownership
Archdiocese Of Miami Inc
5% Or Greater Indirect Ownership Interest · Organization
Villa Maria Nursing & Rehabilitation Center
5% Or Greater Direct Ownership Interest · Organization
Catholic Health Services Inc
Operational/Managerial Control · Organization
Contreras, Jose
Operational/Managerial Control · Individual
Frick, Mary
Corporate Officer · Individual
Johnson, Nathaniel
Operational/Managerial Control · Individual
Wilson, Laura
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Glades West Rehabilitation And Nursing C
Pembroke Pines, FL
5-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Nspire Healthcare Miami Lakes
Hialeah, FL
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Palmetto Care Center And Rehab
Hialeah, FL
5-star overall rating with 4-star inspections with 2 recent health deficiencies
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