Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Memorial Long Term Care Center during CMS and state inspections, most recent first.
A resident with TBI, psychiatric diagnoses, unsteady gait, confusion, and a high fall-risk score had an active MD order for 1:1 supervision and fall precautions. Despite this, the assigned CNA left the bedside and walked down the hall to discuss break coverage instead of using the call light, leaving the resident unsupervised. During this time, the resident exited through a nearby emergency exit door, descended a flight of stairs, and was found at the bottom with multiple abrasions. Facility policy and staff interviews confirmed that 1:1 supervision required the sitter to remain within arm’s length of the resident and to request breaks via call light, and the facility’s neglect policy defined inadequate supervision as neglect.
Multiple residents were exposed to accident hazards due to improper use of side rail padding for a resident with seizures, unsecured hazardous items such as a box cutter in a resident's room, missing required floor mats for two residents at risk for falls, and a cognitively impaired resident keeping cigarettes in violation of the facility's smoking policy. Staff interviews revealed lapses in following established safety protocols and inconsistent monitoring practices.
A resident with an indwelling urinary catheter was found with the catheter tubing positioned above the bladder and kinked, which prevented urine from flowing freely. The tubing was observed protruding from the resident's shorts and attached to a drainage bag on a walker. The resident, who had a history of BPH with obstructive uropathy and UTI, had a care plan instructing not to reposition the catheter above the bladder, but this was not followed. Staff confirmed that proper catheter positioning was not addressed in facility policy.
Surveyors observed two residents with urinary catheter dignity bags touching the floor and a nurse failing to perform proper hand hygiene during tracheostomy care for a resident with chronic respiratory failure. Staff interviews and facility policy confirmed that catheter bags should not touch the floor and that hand hygiene is required after glove removal, but these protocols were not followed, resulting in infection control deficiencies.
Failure to Maintain Required 1:1 Supervision Resulting in Resident Fall Down Stairwell
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a newly admitted, cognitively impaired resident who had an active order for 1:1 supervision and fall precautions. The resident had diagnoses including traumatic brain injury, impulse disorder, generalized anxiety disorder, polyneuropathy, and a healing clavicle fracture, and had a fall risk assessment score of 10 indicating risk for falls. Nursing documentation noted the resident had multiple trips to the bathroom with watery stools, an unsteady gait, confusion, restlessness, and agitation, and was on hourly rounds while staff awaited implementation of 1:1 supervision. Despite an existing physician order for 1:1 supervision to ensure safety and support cognitive recovery, the assigned CNA left the resident’s bedside to walk two doors down the hall to ask another staff member about break coverage after providing the resident with water and covering him in bed. The facility’s policy and staff interviews indicated that 1:1 supervision required the sitter to remain at the bedside at all times, within one arm’s length of the resident, and to use the call light to request breaks rather than leaving the room. During the period the resident was left unsupervised, the resident exited the unit through a nearby emergency exit door located approximately 30 feet from the resident’s room. The resident descended a flight of eight stairs and was found by staff sitting at the bottom of the steps after the exit door alarm sounded. On assessment, the resident had abrasions to the right side of the forehead, the bridge of the nose, the right hand palm, and the right hand fourth digit. The incident occurred in the context of the facility’s own policy defining neglect to include inadequate supervision when a victim is left alone despite a caregiver being present but not providing necessary supervision. Interviews with the risk manager, RN leader, administrator, and DON confirmed that the sitter should not have left the resident alone and that the resident’s restlessness, impulsiveness, and psychiatric/TBI history made continuous supervision necessary under the ordered 1:1 precautions.
Failure to Prevent Accident Hazards and Enforce Safety Policies
Penalty
Summary
The facility failed to provide a safe environment free from accident hazards for multiple residents by not implementing its own policies related to accident prevention and hazard control. For one resident with a seizure disorder and orders for padded side rails, the side rail padding was repeatedly observed improperly positioned on the outside of the rail, rather than secured inside as required. Staff interviews confirmed that the padding was loose and not correctly attached, and that the issue had not been addressed despite ongoing use of the padding for seizure safety. Another resident, who was cognitively intact but had significant physical impairments and a history of behavioral issues, was found to have a bladed box cutter on the bedside table. Staff acknowledged that the resident had been previously instructed not to keep such items, but the box cutter had not been detected during routine checks or after the resident returned from a day pass. The resident admitted to purchasing and using the box cutter for personal activities, and staff interviews revealed inconsistent practices regarding the search of residents' belongings and enforcement of the facility's policy prohibiting weapons and hazardous items. Additional deficiencies included two residents at risk for falls who did not have required bilateral floor mats in place while in bed unattended, contrary to physician orders and care plan interventions. In both cases, staff removed the mats for meal setup and failed to replace them, leaving the residents unprotected. Another resident with severe cognitive impairment and nicotine dependence was observed keeping cigarettes in personal possession, in violation of the facility's smoking policy, which requires all smoking materials to be secured by staff. Staff interviews confirmed that cigarettes were distributed to the resident and not always returned or accounted for as required by policy.
Improper Positioning of Indwelling Urinary Catheter Tubing
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed with the catheter tubing positioned above the bladder and kinked, preventing the free flow of urine. The tubing was seen protruding from the top of the resident's shorts and connected to a drainage bag anchored on a walker. The resident reported blood in the urine, and it was noted that urine was not flowing freely due to the kinked tubing. The resident had a history of benign prostatic hyperplasia with obstructive uropathy and urinary tract infection, and required supervision or assistance for toileting hygiene and catheter care. The care plan indicated the resident had a tendency to touch or reposition the catheter, sometimes placing it above the bladder level, despite instructions to keep it below the bladder to prevent complications. Staff interviews confirmed that the best practice for catheter positioning is to secure the tubing to the thigh and keep the drainage bag below the bladder to prevent backflow. However, the facility did not have a specific policy regarding the proper positioning of indwelling urinary catheters. The facility's existing policy only addressed routine catheter care but did not specify positioning requirements. At the time of the survey, four residents in the facility had indwelling urinary catheters.
Infection Control Deficiencies: Catheter Bag Placement and Hand Hygiene Lapses
Penalty
Summary
Surveyors identified failures in infection control practices involving three residents. Two residents with urinary catheters were observed with their catheter dignity bags touching the floor, as documented by photo evidence. Both residents had significant medical histories, including urinary tract infections, sacral wounds, and dependence on external catheters. Their care plans required catheter bags to be positioned below the bladder and never touch the floor, with staff interviews confirming this expectation. However, observations showed that the dignity bags were not properly secured, resulting in direct contact with the floor. In another instance, a nurse performed tracheostomy care for a resident with chronic respiratory failure and severe cognitive impairment. During the procedure, the nurse failed to perform hand hygiene after removing gloves and before donning new gloves, contrary to facility policy and standard infection control protocols. The nurse stated that handwashing was not performed because no surfaces were touched after glove removal, but both the charge nurse and DON confirmed that hand hygiene is required after glove removal regardless of circumstances. Facility policies reviewed by surveyors clearly outlined the need for proper hand hygiene, including the '5 Moments of Hand Hygiene' and the requirement to perform hand hygiene before donning gloves and after glove removal. Staff interviews further confirmed awareness of these protocols, yet the observed practices did not align with policy, resulting in deficiencies in infection prevention and control measures for the sampled residents.
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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) |
|---|---|---|---|---|
| Unity Healthcare And Rehabilitation Center | 0.8 mi | ★★★★★ | 1 | 0 |
| Jackson Gardens Health And Rehabilitation Center | 1.5 mi | ★★★★★ | 7 | 0 |
| University Health And Rehabilitation Center | 1.5 mi | ★★★★★ | 1 | 0 |
| Riverside Care Center | 2 mi | ★★★★★ | 0 | 0 |
| Victoria Nursing & Rehabilitation Center, Inc. | 2 mi | ★★★★★ | 0 | 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.