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
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.80
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.54
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
5.42
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.88
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.74
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.21
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.94
CMS adjusted RN staffing hours
Adjusted total hours
5.84
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
21%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
13%
Annual nurse turnover · state 42% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.61% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 10.42% · Lower 95% interval 7.43% |
| Discharge to community | 62.84% |
50.57%
12.3 pts better
|
Better than the National Rate · Eligible stays 47 · Observed rate 82.98% · Lower 95% interval 50.98% |
| Medicare spending per beneficiary | 0.68 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 93.62% |
95.27%
1.6 pts worse
|
Numerator 44 · Denominator 47 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 47 |
| Discharge self-care score | 71.05% |
53.69%
17.4 pts better
|
Numerator 27 · Denominator 38 |
| Discharge mobility score | 71.05% |
50.94%
20.1 pts better
|
Numerator 27 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 47 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 40 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 38 · Denominator 38 |
| Discharge function score | 63.16% |
56.45%
6.7 pts better
|
Numerator 24 · Denominator 38 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 38 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 1.3% · 4Q avg 0.6% · Used in QM five-star |
| 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 · 4Q avg 96.1% |
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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