Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Memorial Perdue Medical Center during CMS and state inspections, most recent first.
A resident who smoked was found in bed with two boxes of cigarettes and a lighter stored on and under the cushion of his wheelchair in his room. The resident was cognitively intact and independent with ADLs, and his care plan identified him as a supervised safe smoker. Facility policy stated residents shall not keep lighters with them or in their rooms, yet staff interviews showed the resident kept smoking supplies in his room and the lighter was later obtained from him.
Inaccurate controlled substance accounting was found on a North Wing med cart when two residents' narcotic logs did not match the pill counts on the bingo cards. Staff reported that controlled meds should be documented at the time they are removed and administered, and the facility policy required immediate entry of the date, time, amount given, and nurse signature after administration.
Kitchen staff were observed working in the Nutrition Services area without beard restraints. An employee with a beard was seen taking temperatures on the lunch tray line without a beard guard, and another Food Service Worker and the CDM were also observed without beard guards. Both staff members confirmed they were supposed to be wearing them, and the DON acknowledged that staff with beards should be wearing beard guards if available.
QAPI/QAA activities failed to show an effective plan of action to correct repeated deficiencies for F689 and F867. Survey history showed the facility had been cited previously for these tags, and QAA committee records showed monthly meetings with the Administrator, DON, Medical Director, and other department heads. The facility's QAPI policy stated the committee was to review quality indicators, incident reports, cited deficiencies, and grievances and develop plans of action to correct identified quality deficiencies.
The facility failed to implement effective corrective actions for repeated deficiencies in care planning and accident prevention. Specifically, interventions like placing bilateral floor mats by the beds for two residents were not implemented, and safety measures were not ensured. Previous issues included failing to implement care plan interventions for bleeding precautions and not using bedside rail pads for accident prevention.
A facility failed to accurately code the MDS for a resident, resulting in a discrepancy in the discharge status. The MDS incorrectly indicated a discharge to an acute hospital, while the resident was actually discharged to an ALF. This error was identified during a survey when the surveyor noted the inconsistency between the MDS and the nurse's progress notes. The MDS Coordinator acknowledged the mistake, which was due to incorrect information entry.
A facility failed to accurately code the MDS for a resident, resulting in an incorrect discharge status being recorded. The resident, with a diagnosis including atrial fibrillation, was discharged to an ALF, but the MDS inaccurately documented the discharge as to an acute hospital. The discrepancy was acknowledged by the MDS Coordinator, who noted that the information is typically obtained from Social Services and discussed in meetings.
The facility failed to implement fall prevention measures for two residents, as observed with only one floor mat in place instead of the required bilateral mats. Both residents have a history of falls and severe cognitive impairment, with care plans specifying the need for low beds and bilateral floor mats. Staff interviews revealed inconsistencies in ensuring mats were in place, despite awareness of the orders.
The facility failed to implement adequate fall prevention measures for two residents with severe cognitive impairment and high fall risk. Observations showed that each resident had only one floor mat instead of the required bilateral mats, as per physician orders. Staff interviews revealed lapses in ensuring the presence of floor mats, contributing to the unsafe environment.
The facility experienced a 6.25% medication error rate due to improper administration of medications, including a failure to provide a prescribed Magnesium capsule and incorrect administration of chewable Aspirin. Additionally, an RN administered insulin without ensuring privacy for a resident. The facility's policy requires medications to be reordered in advance to prevent such errors.
A facility failed to maintain a medication error rate below 5%, with a 6.25% error rate identified. An RN did not administer a prescribed Magnesium capsule due to unavailability and attempted to give a chewable Aspirin without instructing the resident to chew it. The RN was unaware of the protocol for chewable medications, and the facility's policy on medication reordering was not followed, leading to the deficiency.
A resident in an LTC facility sustained first and second-degree burns after spilling hot coffee on themselves. The coffee was served by an LPN at a temperature above the facility's policy limit. Observations revealed inconsistent temperature checks and a lack of thermometers in some pantry areas, contributing to the incident.
Smoking Supplies Left Accessible in Resident Room
Penalty
Summary
The facility failed to provide an environment as free of accident hazards as possible for one resident who smoked. During observation, the resident was found in bed with a wheelchair positioned in front of the bed, and two boxes of cigarettes were on the wheelchair cushion with a lighter below the cushion. The resident’s record showed a readmission diagnosis that included muscle weakness, and the quarterly MDS indicated a BIMS score of 15, no cognitive impairment, independence with ADLs, use of a wheelchair, and no behavior concerns since admission or reentry. The resident’s care plan identified the resident as a safe smoker if supervised by staff and included offering, educating, and encouraging use of a smoking apron. The facility policy stated residents shall not keep matches or lighters with them or in their rooms and that lighters are to be kept secured. During interview, the resident stated he kept cigarettes and a lighter under the cushion of his wheelchair and smoked independently on the north wing patio. Staff interviews reflected differing practices regarding whether residents could keep cigarettes, but all agreed lighters were not to be kept by residents; the DON and Risk Manager stated residents were allowed to keep cigarettes but not lighters, and the Risk Manager stated the lighter was later obtained from the resident.
Inaccurate Controlled Substance Accounting on Medication Cart
Penalty
Summary
The facility failed to maintain an accurate accounting of controlled substances on the North Wing's Red Medication Cart, with two narcotic record discrepancies identified during a medication cart check and narcotic accounting review. For Resident #97, the narcotic accounting log for Tramadol HCL 50 mg tablets documented 22 tablets remaining, while the medication bingo card showed 21 pills. For Resident #109, the narcotic accounting log for Oxycodone-Acetaminophen 5/325 mg tablets documented a balance of 52, while the bingo card showed 51 pills. During the review, Staff F, RN stated that the facility's controlled medication accounting process required recording the time in the computer and signing the log to show how many pills remained when a controlled medication was removed from the bingo card. Staff D, RN/North Wing Unit Manager stated that nursing staff were trained to sign the narcotic book at the beginning and end of the shift and to make sure the paper matched the bingo card, and that if a nurse pulled a controlled medication, they signed the book at the time the medication was pulled. The DON also stated that nurses must sign at the time a pill is removed to keep the reconciliation form accurate. The facility policy dated 11/19/2025 stated that when a controlled medication is administered, the licensed nurse administering the medication immediately enters the date and time, amount administered, and signature after the medication is actually administered.
Kitchen Staff Not Wearing Beard Restraints
Penalty
Summary
The facility failed to ensure kitchen staff were wearing beard restraints while working in the Nutrition Services Department. The Personal Appearance and Conduct Restraint Policy and Procedure, reviewed on 06/11/2025, stated that employees working in Nutrition Services must wear hairnets or coverings that cover all of the hair to support safe and sanitary food preparation and service. During observation of the kitchen on 04/29/2026 at 10:56 AM, Staff A, who had a beard, was observed without a beard guard while taking temperatures of food items on the lunch tray line. Staff A confirmed during interview at 11:08 AM that he was not wearing a beard guard and was supposed to have one on. Later that morning, Staff B, a Food Service Worker, and the Certified Dietary Manager were observed, and Staff B also had a beard and was not wearing a beard guard. Staff B confirmed at 11:14 AM that he was not wearing a beard guard and was supposed to have one on. The Certified Dietary Manager confirmed at 11:15 AM that Staff B was not wearing a beard guard and should have one on. The Director of Nutrition Services stated at 11:16 AM that going forward, staff with beards should be wearing a beard guard if they have one.
QAPI/QAA Deficiency Review and Corrective Planning
Penalty
Summary
The facility's QAPI/QAA activities failed to demonstrate an effective plan of action to correct repeated deficiencies in the problem area, as evidenced by repeated deficient practices for F689-Free of Accident and Hazards/Supervision/Devices and F867; QAPI/QAA improvement activities. The facility had 147 residents at the time of survey. Record review of the facility's survey history showed it was cited for F689 and F867 during the recertification and re-licensure survey with an exit date of October 24, 2024. Review of the QAPI Committee Meeting sign-in sheets dated 02/17/2026, 03/17/2026, and 04/21/2026 showed the QAA Committee met monthly and included the Administrator, Medical Director, DON, other department heads, and staff members. During interview, the Administrator stated the members included the Medical Director, nursing home administrator, pharmacist, compliance director, infection preventionist, and some nurses, and that the group met every month and as needed to identify trends and improve quality of care and quality of life. Review of the facility's QAPI Plan policy stated the committee was to assess resident care practices, review facility quality indicators, incident reports, deficiencies cited by AHCA, and resident grievances, and develop plans of action to correct and respond quickly to identified quality deficiencies.
Repeated Deficiencies in Care Planning and Safety Measures
Penalty
Summary
The facility failed to implement effective corrective actions to address repeated deficiencies in care planning and accident prevention. Specifically, the facility did not implement interventions such as placing bilateral floor mats by the beds for two residents, which was a repeated issue from a previous survey. Additionally, the facility did not ensure safety measures were in place for these residents, leading to deficiencies in providing a safe environment. In a prior survey, the facility was cited for failing to implement care plan interventions related to bleeding precautions for two residents and for not developing a comprehensive care plan for a resident with a nephrostomy tube. The facility also failed to provide a safe environment by not using bedside rail pads to prevent accidents for another resident. These repeated deficiencies indicate a lack of effective implementation of care plans and safety measures for residents.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, leading to a discrepancy in the recorded discharge status. Specifically, the MDS for the resident indicated a discharge to an acute hospital, while the resident was actually discharged to an Assisted Living Facility (ALF). This error was identified during a survey when the surveyor reviewed the resident's discharge records and noted the inconsistency between the MDS and the nurse's progress notes, which clearly documented the discharge to an ALF. The resident involved had been admitted to the facility with clinical diagnoses including atrial fibrillation and was discharged as planned to an ALF. The facility's MDS Coordinator acknowledged the error, attributing it to incorrect information being entered into the MDS. The facility's policy emphasizes the importance of accurate MDS coding to ensure quality care and proper Medicare reimbursement, highlighting the significance of this deficiency.
Inaccurate MDS Coding for Resident Discharge Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, leading to a discrepancy in the recorded discharge status. The resident, who had been admitted with a clinical diagnosis including atrial fibrillation, was discharged to an Assisted Living Facility (ALF). However, the MDS inaccurately documented the discharge status as being to an acute hospital. This error was identified during a review of the resident's medical records, which included physician's orders and nurses' progress notes clearly indicating the discharge to an ALF. During an interview, the MDS Coordinator acknowledged the discrepancy, noting that the information for MDS coding is typically obtained from Social Services and discussed in morning meetings. The facility's policy emphasizes the importance of accurate MDS coding for holistic resident assessments and care planning. Despite this, the incorrect code was entered, highlighting a lapse in the facility's adherence to its own procedures for ensuring accurate resident assessments.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement care plan interventions related to falls for two residents, as observed during several inspections. Resident #78 was found in bed with only one fall mat on the right side, despite physician orders requiring bilateral floor mats. This resident has a history of falls, with multiple incidents documented in their care plan, including falls from bed and wheelchair. The care plan outlined specific interventions such as maintaining a low bed and using bilateral floor mats, but these were not consistently followed, as evidenced by the observations. Similarly, Resident #151 was observed with only one floor mat on the left side of the bed, contrary to the physician's orders for bilateral floor mats. This resident also has a history of falls and is at high risk due to decreased functional mobility and severe cognitive impairment. The care plan for this resident included maintaining a low bed and bilateral floor mats, but these interventions were not fully implemented during the observations. Interviews with staff, including CNAs and RNs, revealed that while they were aware of the orders for floor mats, there were inconsistencies in ensuring that the mats were in place. Staff mentioned that floor mats are sometimes removed during care and placed under the bed, and if missing, they would report it to the nurse or maintenance for replacement. The Director of Nursing confirmed that residents are reviewed for fall risks and orders are communicated to staff, but the observations indicate a lapse in adherence to these protocols.
Failure to Implement Adequate Fall Prevention Measures
Penalty
Summary
The facility failed to implement adequate safety measures for two residents, both of whom were at high risk for falls. Observations revealed that these residents were provided with only one floor mat on one side of their beds, despite physician orders specifying the use of bilateral floor mats. This deficiency was noted during multiple observations over consecutive days, indicating a consistent failure to adhere to prescribed safety protocols. Resident #78, who has severe cognitive impairment and a history of falls, was observed with only one floor mat on the right side of the bed. The resident's care plan and physician orders clearly stated the need for a low bed and bilateral floor mats due to the resident's high fall risk and poor safety awareness. Despite these orders, the facility did not ensure the presence of the required safety equipment, as evidenced by repeated observations of the resident's environment. Similarly, Resident #151, also with severe cognitive impairment and a high risk for falls, was observed with only one floor mat on the left side of the bed. The resident's medical records and care plan included orders for a low bed and bilateral floor mats, which were not consistently implemented. Interviews with staff revealed a lack of adherence to procedures for ensuring the presence of floor mats, with staff indicating that missing mats were often placed under the bed during care and not replaced promptly. This systemic issue contributed to the facility's failure to maintain a safe environment for these vulnerable residents.
Medication Administration Errors and Privacy Breach
Penalty
Summary
The facility failed to adhere to pharmacy procedures, resulting in a medication error rate of 6.25% out of 31 opportunities. During a medication administration observation, a Registered Nurse (RN) on the South Wing Nursing Unit did not include a prescribed Magnesium 100 mg capsule in the medication cup for a resident because it was not available in the medication cart. Additionally, the RN attempted to administer a chewable form of Aspirin without instructing the resident to chew it separately. The RN was unaware of the facility's protocol for administering chewable medications and typically administered all medications together. The RN Manager intervened, instructing the RN to ask the resident in Creole about their preference for taking the chewable medication, which was then administered correctly. Another deficiency was observed when an RN on the South Wing Nursing Unit administered insulin to a resident without providing privacy, as another resident was present in the room. The RN did not pull the curtain or close the door, citing the presence of the surveyor as the reason for not ensuring privacy. The Director of Nursing (DON) later confirmed that nurses are responsible for reordering medications when stock is low and ensuring medications are available for administration. The facility's policy requires medications to be reordered at least five days before depletion.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 6.25% error rate during a survey. This deficiency was identified through observations, interviews, and record reviews. Specifically, a medication administration observation revealed that a Registered Nurse (RN) on the South Wing Nursing Unit did not administer a prescribed Magnesium 100 mg capsule to a resident because it was not available in the medication cart, and the pharmacy had not delivered it. Additionally, the RN attempted to administer a chewable Aspirin 81 mg tablet without instructing the resident to chew it, which was against the protocol. The RN was unaware of the exact protocol for administering chewable medications and typically administered all medications together, as the resident did not like to chew the chewable Aspirin. The resident involved had a diagnosis that included prophylactic measures and nutritional deficiency, with a physician's order for chewable Aspirin and Magnesium. The Director of Nursing (DON) confirmed that if a medication is ordered as chewable, it should be chewed based on the resident's preference, and the nurse should instruct the resident accordingly. The facility's policy required medications to be reordered at least five days before depletion, which was not adhered to in this case, leading to the omission of the Magnesium capsule. The RN Manager and a Certified Nursing Assistant (CNA) later intervened to ensure the resident chewed the Aspirin, but the initial failure to follow protocol and ensure medication availability contributed to the deficiency.
Resident Burned by Hot Coffee Due to Inadequate Temperature Checks
Penalty
Summary
The facility failed to ensure the safety of a resident, resulting in the resident sustaining first and second-degree burns from hot coffee spilled on their chest and abdomen. The incident occurred when the resident, who was alert and oriented, requested a cup of coffee. A Licensed Practical Nurse (LPN) provided the coffee with a lid and placed it on the resident's overbed table. The resident accidentally tipped the table, causing the coffee to spill and the lid to pop off, leading to the burns. The coffee temperature was found to be 151 degrees Fahrenheit, which was below the typical serving temperature but above the facility's policy limit of 155 degrees Fahrenheit at the time of delivery to residents. The facility's policy and procedures for serving hot liquids were not consistently followed. Observations revealed that thermometers were not always available in the pantry areas, and staff did not consistently check the temperature of hot beverages before serving them to residents. Interviews with staff indicated a lack of consistent practice in checking coffee temperatures, with some staff relying on visual cues or touch rather than using thermometers. The facility's policy stated that hot liquids should not exceed 155 degrees Fahrenheit at the time of delivery, but the coffee temperatures recorded in the pantries were often above this limit. The resident involved in the incident had a history of pressure ulcers and was receiving treatment for various conditions, including a contusion and an open wound. The resident was independent in feeding and drinking, which contributed to the incident being classified as an accident rather than neglect or abuse. Despite the facility's policy and procedures, the lack of consistent temperature checks and the absence of thermometers in some pantry areas contributed to the resident's injury.
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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 Cutler Bay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| East Ridge Rehabilitation And Nursing Center | 0.5 mi | ★★★★★ | 5 | 0 |
| South Dade Nursing And Rehabilitation Center | 2.4 mi | ★★★★★ | 5 | 0 |
| Coral Reef Subacute Care Center Llc | 3.3 mi | ★★★★★ | 1 | 0 |
| St Annes Nursing Center, St Annes Residence Inc | 3.6 mi | ★★★★★ | 4 | 0 |
| Harmony Health Center | 7.2 mi | ★★★★★ | 0 | 0 |
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