Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Interview with
the Director of Nursing/Abuse Coordinator/Risk Manager on 2/17/25 at 11:25 AM. He stated, She did not
have a fall. She hit her head with the wheelchair. The CNA was trying to transfer her from the bed to the
wheelchair. She pulled the wheelchair closer to the bed and she let the resident go while she was sitting on
the edge of the bed. The bruises did not come right away. At the moment, she didn't have a bruise. The
incident was on 2/01/25, the bruises were noticed on 2/03/25. When the incident happened, she didn't have
any bruises, the bruises were noted on 2/03/25. The family came and saw the patient and asked the nurse
and she hadn't noticed the bruises. The CNA did not notify the facility about the incident on 2/01/25 and she
was supposed to. She was reprimanded for not telling anyone about the incident. She did not have a fall.
She hit her head on the handrest of the wheelchair. We did an incident report. The doctor was notified, an
order was given for x-rays of the sacrum and coccyx. There were no fractures.
Interview with Staff A, CNA on 2/17/25 at 12:52 PM via Spanish translator. She revealed on 2/01/25, she
bathed the resident, dressed her and she was going to transfer her to the wheelchair. She had her on the
edge of the bed, she held her with one hand and held the wheelchair with the other. The resident lost
control of her body and leaned forward, and she bumped her head on the wheelchair handrest. The correct
way to transfer a resident from the bed to the wheelchair is that you grab the resident, have them stand and
then turn them. She confirmed that the wheelchair was not positioned before transferring the resident. She
checked her and she didn't see anything and didn't think she had to report it. She was supposed to report
the incident to the nurse but did not.
Interview with Staff B, Registered Nurse (RN) on 2/17/25 at 1:19 PM. She stated, I work from 7:00 AM to
7:00 PM and during the day skilled nursing was done. The resident had no complaints of pain. After dinner,
the daughter visited and asked me about something on her head. Throughout the day I never saw anything
on her head. When I looked on the left side of her head under the hair, I saw the bruising. I did not see any
bruise on her hand. I made an assessment head to toe. Her vital signs were stable and no complaint of
pain. I called the DON/Abuse Coordinator and reported the bruise on 2/03/25. I called the doctor, and he
gave an order for an x-ray. The x-ray was negative. I endorsed it to the night shift for neuro checks. The CNA
is supposed to tell the nurse when something happens and if they hit their head.
Record review of the Accidents and Incidents-Investigating and Reporting Policy and Procedure (revision
date July 2017, reviewed January 2025); Policy Statement-All accidents or incidents involving residents,
employees, visitors, vendors, occurring on our premises shall be investigated and reported to the
administrator; Policy Interpretation and Interpretation -2h) The date/time the injured person's family was
notified and by whom.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
106100
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
106100
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
University Health and Rehabilitation Center
724 NW 19th St
Miami, FL 33136
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Based on records reviewed and interviews the facility failed to immediately inform the resident's
representative and physician about an accident that resulted in an injury which required medical attention
for one resident (Resident #1) out of four sampled residents, as evidenced by during assisted transfer
Resident#1 hit her head on the wheelchair and the incident went unreported after bruising was identified
and reported the family member to staff. There were 143 residents residing in the facility at the time of the
survey.
The findings included:
On 2/17/25 at 8:15 AM Resident#1 was observed in bed with eyes open repeating the word NO when
greeted, a small discoloration was noted under the right eye, a scratch was noted on the right hand and a
small scratch on the left leg.
Record review of a demographic sheet for Resident#1 revealed an initial admission date of 12/15/21 and
readmission date of 8/8/24 with diagnosis that included: Dementia and Unspecified fall.
Record review of an Annual Minimum Data Set reference dated 12/27/24 revealed Resident#1 is
moderately impaired cognitively, required substantial/maximal assistance for chair/bed-to-chair transfer and
had no falls since admission/entry or reentry or the prior assessment.
Further review of a care plan initiated on 12/15/21 and revised on 10/15/24 revealed Resident#1 is at risk
for falls related to muscle weakness, impaired mobility and had a fall that occurred on 4/1/24, had goals to
have no episodes of falls and suffer no injuries from falls. The interventions included: Encourage resident to
ask for assistance when attempting to transfer.
Review of a physician's order sheet revealed orders dated 11/24/24 for fall precaution every shift and order
dated 8/8/24 for bed in lowest position every day and night shift.
Review of progress notes revealed no documentation related to the incident that occurred during the
resident's transfer.
Record review of a Fall Risk assessment dated [DATE] revealed Resident#1 was at a low risk for falls.
Review of a skin check dated 2/1/25 revealed Resident #1's skin was intact with no redness or bruising
noted.
On 2/17/25 at 11:35 AM, the Director of Nursing (DON) stated, After witnessing or discovering that a
resident had a fall or injury of unknown origin, the protocol is for the staff to report to the doctor and family,
we do an incident report and staff should document. Staff monitor residents to prevent fall depending on
their risk for example by taking residents to activities. [Resident#1] hit her head on the arm rest of the
wheelchair during transfer because the Certified Nursing Assistant was not looking or holding the resident
for a moment. [Resident #1] was listed on the Incident Log for 2/1/25 after The CNA reported to us on
2/3/25 that the resident hit her head on the wheelchair during transfer. When an incident report is
completed, it triggers for other assessments. The Skin check is dated 2/1/25 because the incident
happened on that date, but I completed the Skin check for the Resident on 2/3/25.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106100
If continuation sheet
Page 2 of 4
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
106100
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
University Health and Rehabilitation Center
724 NW 19th St
Miami, FL 33136
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Interview with
the Director of Nursing/Abuse Coordinator/Risk Manager on 2/17/25 at 11:25 AM. He stated, She did not
have a fall. She hit her head with the wheelchair. The CNA was trying to transfer her from the bed to the
wheelchair. She pulled the wheelchair closer to the bed and she let the resident go while she was sitting on
the edge of the bed. The bruises did not come right away. At the moment, she didn't have a bruise. The
incident was on 2/01/25, the bruises were noticed on 2/03/25. When the incident happened, she didn't have
any bruises, the bruises were noted on 2/03/25. The family came and saw the patient and asked the nurse
and she hadn't noticed the bruises. The CNA did not notify the facility about the incident on 2/01/25 and she
was supposed to. She was reprimanded for not telling anyone about the incident. She did not have a fall.
She hit her head on the handrest of the wheelchair. We did an incident report. The doctor was notified, an
order was given for x-rays of the sacrum and coccyx. There were no fractures.
Interview with Staff A, CNA on 2/17/25 at 12:52 PM via Spanish translator. She revealed on 2/01/25, she
bathed the resident, dressed her and she was going to transfer her to the wheelchair. She had her on the
edge of the bed, she held her with one hand and held the wheelchair with the other. The resident lost
control of her body and leaned forward, and she bumped her head on the wheelchair handrest. The correct
way to transfer a resident from the bed to the wheelchair is that you grab the resident, have them stand and
then turn them. She confirmed that the wheelchair was not positioned before transferring the resident. She
checked her and she didn't see anything and didn't think she had to report it. She was supposed to report
the incident to the nurse but did not.
Interview with Staff B, Registered Nurse (RN) on 2/17/25 at 1:19 PM. She stated, I work from 7:00 AM to
7:00 PM and during the day skilled nursing was done. The resident had no complaints of pain. After dinner,
the daughter visited and asked me about something on her head. Throughout the day I never saw anything
on her head. When I looked on the left side of her head under the hair, I saw the bruising. I did not see any
bruise on her hand. I made an assessment head to toe. Her vital signs were stable and no complaint of
pain. I called the DON/Abuse Coordinator and reported the bruise on 2/03/25. I called the doctor, and he
gave an order for an x-ray. The x-ray was negative. I endorsed it to the night shift for neuro checks. The CNA
is supposed to tell the nurse when something happens and if they hit their head.
Record review of the Accidents and Incidents-Investigating and Reporting Policy and Procedure (revision
date July 2017, reviewed January 2025); Policy Statement-All accidents or incidents involving residents,
employees, visitors, vendors, occurring on our premises shall be investigated and reported to the
administrator; Policy Interpretation -2h) The date/time the injured person's family was notified and by whom.
Based on interviews and record reviews, the facility failed to ensure one resident (Resident #1) out of four
sampled residents received adequate supervision to prevent accidents as evidenced by during transfer,
Resident #1 sustained injuries that were not reported immediately by staff and were discovered by a family
member.
The findings included:
On 2/17/25 at 8:15 AM Resident#1 was observed in bed with eyes open repeating the word NO when
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106100
If continuation sheet
Page 3 of 4
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
106100
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
University Health and Rehabilitation Center
724 NW 19th St
Miami, FL 33136
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
greeted, a small discoloration was noted under the right eye, a scratch was noted on the right hand and a
small scratch on the left leg.
Record review of a demographic sheet for Resident#1 revealed an initial admission date of 12/15/21 and
readmission date of 8/8/24 with diagnosis that included: Dementia and Unspecified fall.
Residents Affected - Few
Record review of an Annual Minimum Data Set reference dated 12/27/24 revealed Resident#1 is
moderately impaired cognitively, required substantial/maximal assistance for chair/bed-to-chair transfer and
had no falls since admission/entry or reentry or the prior assessment.
Further review of a care plan initiated on 12/15/21 and revised on 10/15/24 revealed Resident#1 is at risk
for falls related to muscle weakness, impaired mobility and had a fall that occurred on 4/1/24, had goals to
have no episodes of falls and suffer no injuries from falls. The interventions included: Encourage resident to
ask for assistance when attempting to transfer.
Review of a physician's order sheet revealed orders dated 11/24/24 for fall precaution every shift and order
dated 8/8/24 for bed in lowest position every day and night shift.
Review of progress notes revealed no documentation related to the incident that occurred during the
resident's transfer.
Record review of a Fall Risk assessment dated [DATE] revealed Resident#1 was at a low risk for falls.
Review of a skin check dated 2/1/25 revealed Resident #1's skin was intact with no redness or bruising
noted.
On 2/17/25 at 11:35 AM, the Director of Nursing (DON) stated, After witnessing or discovering that a
resident had a fall or injury of unknown origin, the protocol is for the staff to report to the doctor and family,
we do an incident report and staff should document. Staff monitor residents to prevent fall depending on
their risk for example by taking residents to activities. [Resident#1] hit her head on the arm rest of the
wheelchair during transfer because the Certified Nursing Assistant was not looking or holding the resident
for a moment. [Resident #1] was listed on the Incident Log for 2/1/25 after The CNA reported to us on
2/3/25 that the resident hit her head on the wheelchair during transfer. When an incident report is
completed, it triggers for other assessments. The Skin check is dated 2/1/25 because the incident
happened on that date, but I completed the Skin check for the Resident on 2/3/25.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106100
If continuation sheet
Page 4 of 4
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the February 17, 2025 survey of UNIVERSITY HEALTH AND REHABILITATION CENTER?
This was a inspection survey of UNIVERSITY HEALTH AND REHABILITATION CENTER on February 17, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at UNIVERSITY HEALTH AND REHABILITATION CENTER on February 17, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.