Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Jackson Gardens Health And Rehabilitation Center during CMS and state inspections, most recent first.
Unlocked AC unit rooms were found on the 4th and 2nd floors during a tour, and both doors could be locked from the inside. No staff were observed nearby. The Maintenance Director stated the rooms are mechanical rooms that should be kept locked, and Corporate Maintenance said the doors had been left open for housekeeping to clean.
Medication storage and labeling were deficient on two med carts and in a med room refrigerator. Open eye drops and insulin pens were found without open dates, one eye drop box had labels for two residents, a loose pill was in a cart, and the refrigerator holding meds was at 58°F instead of the required 36 to 46°F. Staff said open dates are written on multi-dose meds and that expired meds are removed, but several items on the carts were not labeled as required.
Failure to honor a resident’s food preferences and therapeutic diet needs. A resident with Crohn’s disease, IBS, and other chronic conditions repeatedly received trays with foods she said she could not eat, including gravy, pork with gravy, cheese, milk, and other items she reported would upset her stomach. Although staff knew several of her dislikes and her care plan directed that food preferences be honored, meal tickets and menus showed no diet modifications for her condition.
Improper indwelling catheter care was identified for two residents when catheter tubing was observed coiled rather than positioned straight for drainage. One resident with a suprapubic catheter had cloudy urine in the tubing and a history of UTI, while the other resident had severe cognitive impairment and urine present throughout the coiled tubing. Staff interviews confirmed that catheter tubing should be positioned straight to support urine flow and reduce obstruction.
A resident receiving continuous O2 had a humidifier canister left unchanged beyond the weekly order. Another resident’s bloody dressing from a suprapubic catheter change was placed in the bedside trash instead of biohazard waste. A third resident with EBP orders for a PEG, dialysis catheter, and wound received hygiene care and linen-related care without the required gown, despite the facility’s EBP policy calling for gowns and gloves during high-contact care activities.
The facility failed to follow infection control standards for two residents, leading to deficiencies. One resident had an unlabeled enteral feeding syringe, and staff did not wear a gown during care, despite enhanced barrier precautions being required. Another resident with an IV site lacked an Enhanced Barrier Precaution sign, and staff did not adhere to the facility's policy for using gowns and gloves during care.
The facility failed to protect resident information privacy, as surveyors observed multiple instances of unattended computer screens displaying sensitive data. Staff members admitted to leaving screens open while attending to other tasks, contrary to the facility's policy. The DON confirmed that screens should be closed when unattended to safeguard resident confidentiality.
A resident with severe cognitive impairment was found in bed with a bed control that had exposed wires and a shaving razor on a light fixture above them. The RN removed the razor but did not dispose of it in a sharps container as required. The maintenance director replaced the bed control, noting it was low voltage. Facility policies on safety precautions and sharps disposal were not followed.
A significant medication error occurred when an RN crushed a Nifedipine ER tablet and mixed it with applesauce for a resident. The RN was unsure if the medication could be crushed, and there was no list of medications that should not be crushed on the cart. The ADON, Pharmacy consultant, and DON confirmed that extended-release tablets should not be crushed.
The facility failed to secure medication carts, with two out of six observed unlocked and unattended. An RN left a cart open due to nervousness, while an LPN left another cart unlocked when attending to a colleague. Both acknowledged the protocol to lock carts when unattended, confirmed by the DON.
The facility was cited for failing to implement effective infection prevention and control measures, as staff were observed not wearing correct PPE during care of residents on Enhanced Barrier Precautions and an enteral feeding syringe was found unlabeled. This deficiency was noted during a recertification survey, with 112 residents present at the time.
Unlocked AC Unit Rooms
Penalty
Summary
The facility failed to maintain an environment free of accident hazards when two of three air conditioning unit rooms, located on the fourth floor and second floor, were found unlocked during an observational tour. The doors to both AC unit rooms were lockable from the inside, and no staff members were observed near these rooms at the time of the tour. Record review showed the facility’s Safety Precautions policy required all personnel to follow general safety precautions established by the facility. The Maintenance Director stated the AC unit rooms are mechanical rooms that should be kept locked and that only maintenance personnel retain the key, while Corporate Maintenance staff stated the rooms had been left open for housekeeping to clean and that the doors are to be locked.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles on two fourth-floor medication carts and in the second-floor medication room. On fourth-floor medication cart 2, a Ketorolac Tromethamine ophthalmic solution box labeled for one resident also had an additional label for another resident, and the bottle was open with no open date on the bottle or box. The same cart also contained open Timolol Maleate and Moxifloxacin ophthalmic solutions with no open dates, several insulin pens for multiple residents with open dates and beyond-use dates recorded, and other insulin pens that were open with no open date written. One loose white pill was also observed in the cart. On fourth-floor medication cart 1, an open Latanoprost ophthalmic solution for one resident and an open Brimonidine ophthalmic solution for another resident were both found without open dates on the bottle or bag. Record review showed the residents had active orders for the eye drops and insulins found on the carts, including treatment for cataracts, glaucoma, ocular hypertension, and diabetes mellitus. The consultant pharmacist stated that multi-dose medications must be dated after opening and that insulin pen injectors can generally be kept opened on the medication cart for 28 days. Staff stated that they write open and expiration dates on opened insulins and eye drops, but one RN did not explain how expiration is determined when an open date is missing, and another RN said the pharmacy dispensed date was used. The second-floor medication room refrigerator was observed at 58 degrees Fahrenheit, above the stated storage range of 36 to 46 degrees Fahrenheit. Staff stated the temperature had been increased to thaw insulin, and another RN stated the refrigerator door had been left open, causing the temperature to rise. The pharmacist confirmed the proper refrigerator range, and the facility policy required refrigerated medications to be stored between 36 and 46 degrees Fahrenheit with daily temperature checks. The report also noted that staff were expected to check carts at the end of each shift and remove expired medications.
Failure to Honor Resident Food Preferences and Therapeutic Diet Needs
Penalty
Summary
The facility failed to accommodate one resident’s food preferences and therapeutic diet needs for a resident with Crohn’s disease, irritable bowel syndrome, atrial fibrillation, hypertension, insomnia, major depressive disorder, and anxiety. The resident was able to make her needs known and was documented as requiring partial to moderate assistance with eating. Her care plan included honoring food preferences, and staff interviews showed awareness that she did not like fish, ham, rice, fried foods, greasy foods, hard boiled eggs, milk, cheese, or gravy, and that she preferred peanut butter and jelly sandwiches. During multiple observations, the resident repeatedly received foods she stated she could not eat or did not want because of her Crohn’s disease. Her trays included items such as baked chicken with gravy, potatoes with skin, mixed vegetables, cream of potato soup, pork roast with gravy, yucca, navy bean soup, scrambled eggs with cheese, sausage, cheese grits, and milk products. The resident stated that she could not eat gravy, pork with gravy, eggs with cheese, or milk, and that she had told the dietitian about these preferences. She was observed eating only selected items from the trays, often leaving most of the meal uneaten. Record review showed the resident was on a NAS regular diet with thin liquids, and the nutrition care plan directed staff to provide the diet as ordered and tolerated, sandwich lunch and dinner, and honor food preferences and update as needed. However, review of the meal tickets and the 4-cycle menus for May 4-7, 2026 showed the resident’s liked and disliked foods were noted, but no modifications were made to accommodate her Crohn’s disease. Staff interviews reflected that the resident’s preferences were known, yet the meals continued to include foods she reported she could not tolerate.
Improper Indwelling Catheter Tubing Positioning
Penalty
Summary
Appropriate catheter care and care to prevent urinary tract infections were not provided for two residents with indwelling urinary catheters. On 05/04/2026 and again on 05/05/2026, Resident #79 was observed in bed with a suprapubic indwelling urinary catheter tubing formed into a circle, and urine in the tubing appeared cloudy. Resident #79 had diagnoses including a personal history of UTI and a stage 4 sacral pressure ulcer, was cognitively intact with a BIMS score of 15/15, and was dependent for toileting hygiene. The resident’s care plan directed staff to check catheter tubing for patency, position the catheter bag and tubing to promote drainage, and monitor for cloudiness and report abnormalities as needed. The physician’s orders included suprapubic catheter care every shift, and a urology consult stated that proper catheter positioning and gravity drainage were to be maintained at all times. Resident #86 was also observed on 05/04/2026 and 05/05/2026 lying in bed with indwelling urinary catheter tubing coiled and urine present throughout the tubing. Resident #86 had diagnoses including BPH with lower urinary tract symptoms and neuromuscular dysfunction of the bladder, had severe cognitive impairment with a BIMS score of 03/15, and required substantial to maximal assistance for toileting hygiene. The resident’s care plan included urinary catheter interventions such as monitoring for pain or discomfort and signs and symptoms of UTI, and the physician’s orders included indwelling urinary catheter care every shift. During interviews, an RN stated catheter tubing should be positioned straight to prevent obstruction, the Infection Preventionist stated catheters are to be positioned straight to prevent UTI, and the DON stated indwelling urinary catheters are to be positioned as straight as possible for urine flow to prevent obstruction that can cause infection.
Infection Prevention and Control Lapses During Oxygen Care, Dressing Disposal, and Enhanced Barrier Precautions
Penalty
Summary
The facility did not consistently implement its infection prevention and control program for residents receiving oxygen therapy and for residents ordered Enhanced Barrier Precautions. For Resident #81, who had diagnoses including chronic respiratory failure with hypercapnia and COPD and was receiving continuous oxygen at 2 LPM via nasal cannula, observations on 05/04/2026 and 05/05/2026 showed the humidifier canister dated 4/26/26. The resident’s physician order required the humidifier bottle to be changed once weekly on Sunday during the night shift and as needed, and the care plan directed that the humidifier, cannula, or mask be changed per protocol. For Resident #79, who had diagnoses including UTI and neuromuscular dysfunction of bladder and had an order for Enhanced Barrier Precautions, Staff I, RN performed a suprapubic catheter dressing change while the removed dressing contained bloody drainage. The soiled dressing was placed in the resident’s bedside trash can rather than being disposed of as infectious waste. A follow-up observation later showed the trash remained in the bedside trash can. The resident’s care plan directed Enhanced Barrier Precautions during dressing changes, bathing, transferring, hygiene, linen changes, toileting assistance, device care, and wound care. For Resident #8, who had severe cognitive impairment, was dependent for toileting, and had orders and care plan interventions for Enhanced Barrier Precautions related to a PEG, dialysis catheter, and wound, Staff J was observed providing hygiene care while wearing a mask and gloves but not the required gown. The facility’s policy stated that Enhanced Barrier Precautions require gowns and gloves for high-contact care activities such as providing hygiene and changing linens. During interview, Staff I acknowledged the humidifier had not been changed in more than a week and that the bloody dressing should have been placed in a biohazard bag and bin, and Staff J stated a gown should have been worn.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control standards for two residents, leading to deficiencies in their care. For Resident #92, the surveyor observed an unlabeled enteral feeding syringe hanging on a tube feeding pole on multiple occasions. The resident, who required enhanced barrier precautions due to an open wound and tube feeding, did not have the necessary precautions maintained. A Certified Nursing Assistant was observed providing hygiene care without wearing a gown, contrary to the facility's policy for enhanced barrier precautions. The Licensed Practical Nurse admitted to not noticing the unlabeled syringe, which should have been labeled by the overnight shift to ensure it was new. For Resident #101, the surveyor noted the absence of an Enhanced Barrier Precaution (EBP) sign for a resident with an intravenous (IV) site. The resident was receiving IV antibiotic therapy for osteomyelitis and required enhanced barrier precautions for a PICC line. Despite the facility's policy requiring a red sticker to indicate EBP, no such indication was present. The Infection Preventionist confirmed the requirement for disposable gowns and gloves during care, which was not observed in practice. The facility's policy on Enhanced Barrier Precautions, revised in April 2024, mandates the use of gowns and gloves during high-contact care activities for residents at increased risk of acquiring multidrug-resistant organisms. However, the observations and interviews revealed lapses in following these protocols, resulting in deficiencies in infection control practices for the residents involved.
Failure to Protect Resident Information Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records, as evidenced by multiple instances of unattended computer screens displaying sensitive information. On the fourth floor, a surveyor observed a computer screen on a medication cart with resident health information visible and unattended. A Registered Nurse admitted to leaving the screen open while responding to a call light, acknowledging the mistake and the importance of closing the screen to ensure privacy. Further observations included a Licensed Practical Nurse leaving a computer screen open at the nursing station while attending to a resident's request, and another LPN leaving a medication cart unlocked with the computer screen open while retrieving medication. Both staff members recognized their failure to adhere to the facility's policy of closing screens and locking carts to protect resident information. The Director of Nursing confirmed that computer screens should be closed when unattended, aligning with the facility's policy to safeguard resident confidentiality and privacy.
Safety Hazards in Resident's Environment
Penalty
Summary
The facility failed to maintain a safe environment for Resident #79, who was observed in bed with a bed control that had exposed wires and a shaving razor placed on top of the light fixture above the resident. The resident, who has severe cognitive impairment and is dependent on assistance for all activities of daily living, was at risk due to these potential safety hazards. The presence of the exposed wires and the razor posed a risk of injury, especially given the resident's cognitive and physical vulnerabilities. Staff J, a registered nurse, was informed of the situation and removed the razor, disposing of it improperly in a biohazard bag instead of a sharps container, as required by facility policy. The Corporate Maintenance Director later replaced the bed control, stating it was low voltage and posed no risk of electrocution. The facility's policy on safety precautions requires all personnel to report broken or defective equipment and to follow established procedures for discarding sharps, which were not adhered to in this instance.
Significant Medication Error: Crushing of Extended-Release Tablet
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a Registered Nurse (RN) who crushed a Nifedipine Extended-Release (ER) 60mg tablet and mixed it with applesauce for administration to a resident. During a medication administration observation, the RN was questioned by a surveyor about the appropriateness of crushing the medication. The RN admitted uncertainty about whether the medication could be crushed, citing a lack of indication on the pharmacy label. The RN acknowledged that crushing the extended-release tablet could result in a rapid release of the medication, potentially harming the resident. Further investigation revealed that the facility did not have a list of medications that should not be crushed available on the medication cart. The Assistant Director of Nursing (ADON) confirmed that extended-release tablets should not be crushed. Additionally, the Pharmacy consultant and the Director of Nursing both stated that extended-release tablets are never to be crushed. The facility's policy on administering medication emphasized that medications should be administered safely, timely, and as prescribed, in accordance with prescriber orders.
Medication Storage Deficiency
Penalty
Summary
The facility failed to properly store medications as evidenced by two out of six medication carts being observed unlocked and unattended. On one occasion, a Registered Nurse (RN) left a medication cart open while knocking on a resident's door. When questioned by the surveyor, the RN admitted to leaving the cart unlocked due to nervousness, acknowledging that the protocol requires the cart to be locked when unattended to ensure resident safety. In another instance, a Licensed Practical Nurse (LPN) left a medication cart unlocked while retrieving medication from it and attending to another nurse. The LPN acknowledged that the cart should be locked when unattended, explaining that it was left open because the surveyor requested to see the cart. The Director of Nursing confirmed that the facility's policy mandates that medication carts be locked when not in use. The facility's policy on medication storage emphasizes the importance of storing drugs and biologicals in a secure manner.
Infection Control Deficiency Due to Improper PPE Use and Unlabeled Syringe
Penalty
Summary
The facility failed to implement effective infection prevention and control measures, as evidenced by staff not wearing the correct personal protective equipment (PPE) during the care of residents on Enhanced Barrier Precautions (EBP) and an unlabeled enteral feeding syringe observed during a recertification survey. This deficiency was identified in the context of a previous citation for infection control practices related to hand hygiene during dining observations, which occurred during a recertification survey conducted from June 19, 2023, to June 22, 2023. The facility's Quality Assurance and Performance Improvement (QAPI) policy, revised in January 2024, emphasizes the development and maintenance of a comprehensive data-driven program focusing on care outcomes and quality of life. Despite this policy, the facility's infection control practices were found lacking, as evidenced by the repeated citation for F880-Infection Prevention and Control. At the time of the survey, there were 112 residents residing in the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Miami
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| University Health And Rehabilitation Center | 0.1 mi | ★★★★★ | 1 | 0 |
| Unity Healthcare And Rehabilitation Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Riverside Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Victoria Nursing & Rehabilitation Center, Inc. | 1.2 mi | ★★★★★ | 0 | 0 |
| Jackson Memorial Long Term Care Center | 1.5 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.