Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Miami Jewish Health Systems, Inc during CMS and state inspections, most recent first.
A resident with dementia, functional quadriplegia, severe cognitive impairment (low BIMS), a documented history of multiple falls, and a care plan identifying high fall risk and need for close supervision was escorted in a wheelchair by a CNA to an auditorium doorway and then left unattended with the wheelchair brakes unlocked. While the CNA was inside the auditorium, the wheelchair rolled, the resident fell onto the pavement, and sustained a head laceration and intracranial injuries requiring hospital admission. Records showed longstanding fall precautions ordered every shift, and staff interviews confirmed awareness that wheelchair brakes should be locked and that the resident required substantial/maximal assistance with transfers.
Unattended medication carts on two floors were observed with unlocked computer screens displaying resident information during med pass. Staff C, RN said she did not realize the screen was left open, and Staff D, RN said he briefly stepped away to assist a resident and returned right back. The facility policy required carts to be locked when out of sight and resident information to remain private, and the DON stated screens should never be left open unattended.
Oxygen therapy was not maintained as ordered for a resident with acute respiratory failure and other cardiac diagnoses. An LPN observed the resident in bed with O2 running at 2 LPM via NC, but the NC was not in the nostrils until the tubing was repositioned. The resident was cognitively impaired, dependent for care, and staff reported the resident frequently pulled the tubing off, requiring frequent rounds and repositioning.
An LPN failed to reconcile controlled substances on a medication cart for two residents, with count sheet totals not matching the bingo card/packet counts for clonazepam and lacosamide. The LPN said she forgot to sign out the meds and was trying to do so before surveyors arrived, then entered one dose after the fact. EMAR review showed both meds were administered earlier that morning, and the LPN stated facility policy requires controlled substances to be signed out immediately after removal and documented after administration.
Infection prevention and control procedures were not followed for two residents when respiratory equipment was observed at the bedside without protective covering. One resident with COPD and chronic respiratory failure had an Incentive Spirometer on the bedside table uncovered, and another resident with acute and chronic respiratory failure had a BIPAP machine uncovered on the bedside table. Staff stated respiratory equipment is normally stored in dated resealable plastic bags when not in use.
Two residents with severe cognitive impairment and orders for electronic wander/elopement alarms were observed wearing these devices, but their Annual MDS assessments inaccurately documented that the devices were not used. The discrepancy was due to an oversight by the MDS Coordinator, despite clear physician orders and care plan interventions requiring the alarms.
The facility failed to administer medications as ordered for two residents, leading to deficiencies in pharmaceutical services. A resident received an incorrect dose of Lactulose, while another did not receive Midodrine as scheduled, resulting in high blood pressure. The DON acknowledged the errors, and the staff pharmacist noted that routine orders for Midodrine typically lack parameters. The facility's policy emphasizes adherence to prescribed medication orders, but these incidents highlight lapses in the system.
The facility failed to ensure proper storage and labeling of medications. An LPN left a medication cart unlocked and unattended, with a medical ointment on top. Additionally, an RN administered a different dosage of Lactulose than what was labeled. The facility's policy requires medications to be stored securely and properly.
A LTC facility failed to administer medications as ordered for two residents. One resident received an incorrect dosage due to a discrepancy between the physician's order and the medication label. Another resident did not receive scheduled medication for high blood pressure, leading to a physician-ordered dosage adjustment. These incidents highlight a failure to adhere to medication administration policies.
The facility failed to properly store and administer medications, as evidenced by an LPN leaving a medication cart unlocked and unattended, and an RN administering a different dosage than labeled. The LPN admitted the cart should have been locked, and the RN's administration did not match the labeled instructions, highlighting discrepancies in medication handling.
The facility failed to complete self-administration of medication assessments for two residents, leading to unauthorized medications being kept at their bedsides. Both residents had medications without proper assessments or physician's orders, and staff were unaware of their ability to self-medicate.
Failure to Supervise High-Risk Resident in Wheelchair Leading to Fall and Head Injury
Penalty
Summary
Staff failed to ensure a safe, supervised environment for a vulnerable resident at high risk for falls, resulting in a fall with major head injury. Video footage from the date of the incident showed a CNA escorting Resident #1, who was seated in a wheelchair, to the door of the auditorium. The CNA left the resident unattended at the doorway, did not lock the wheelchair brakes, and went inside the auditorium, leaving the resident outside without supervision. While the CNA was inside, the resident’s unlocked wheelchair began to roll until it contacted the sidewalk, at which point the resident fell from the wheelchair onto the pavement. Nursing documentation from that day indicated that around the time of the incident, the resident was assessed near the auditorium and found with a laceration to the left forehead and significant bleeding, and was transported by ambulance to a hospital. Subsequent nursing notes and hospital records documented that the resident was diagnosed with a cerebral brain bleed, contusion and laceration of the cerebrum, and brain hemorrhage, and that the resident was admitted to the hospital and later returned to the facility. Clinical records showed the resident had diagnoses including fall from non-moving wheelchair, diffuse traumatic brain injury with loss of consciousness, dementia, functional quadriplegia, and left-hand contracture. The resident’s records demonstrated a long-standing, documented high risk for falls, with multiple fall risk assessments over several years consistently indicating high fall risk and a fall history including several prior falls. The care plan, initiated and revised over time, identified the resident as high risk for falls related to history of falls, impaired mobility, difficulty communicating needs, unsteady gait, poor safety awareness, muscle weakness, left-sided weakness, psychotropic medication side effects, and overestimation of abilities, with interventions such as close supervision and encouraging the resident to remain in supervised areas when in a wheelchair. A recent MDS showed severely impaired cognition (BIMS score of 3/15) and a need for substantial/maximal assistance with transfers. After the incident, staff interviews confirmed that the CNA did not remember locking the wheelchair, acknowledged awareness that the wheelchair should be locked, and other staff reported that the resident required more assistance and had slower responses since returning from the hospital.
Unattended Medication Carts Exposed Resident Information
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential when two medication carts were observed unattended with unlocked computer screens displaying resident information. On 09/16/2025 at 9:47 AM, Medication Cart 2 on the 5th floor was left unattended with the computer screen unlocked and visible resident information displayed. The surveyor notified Staff C, RN, who stated she did not realize she had left the computer screen open. On 09/16/2025 at 10:15 AM, Medication Cart 1 on the 1st floor was also observed unattended with the computer screen unlocked and resident information visible. The surveyor notified Staff D, RN, who stated he had only stepped a few feet away to assist a resident and came right back. Record review of the facility policy titled, Preparation and General Guidelines: May 2022, stated that during medication administration the medication cart is to be kept closed and locked when out of sight of the medication nurse or aide, and resident information must remain private at all times by closing the MAR book or covering the MAR sheet or computer screen when not in use. During interview, the DON stated that before leaving the cart, staff lock it and ensure all resident information is secure, and that the computer screen is never left open unattended and locks automatically every 30 seconds. Staff C, RN stated she receives frequent education on privacy and HIPAA, and Staff D, RN stated he had recently received privacy and HIPAA education during virtual training and with his preceptor.
Oxygen Therapy Not Maintained as Ordered
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for one resident with a primary diagnosis of acute respiratory failure. On 09/16/2025 at 11:07 AM, the resident was observed in bed with eyes closed while oxygen was running at 2 LPM via nasal cannula, but the cannula was not in the resident's nostrils. At 11:14 AM, an LPN repositioned the oxygen tubing into the resident's nostrils and checked the oxygen saturation, which read 100. The resident's record showed admission to the facility with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris. The physician's orders for September 2025 included oxygen 2 LPM via nasal cannula continuously every shift for shortness of breath. The quarterly MDS documented the resident as cognitively impaired, dependent for care, and receiving oxygen therapy. The care plan stated the resident was on oxygen therapy continuously every shift for shortness of breath and that the resident would have no signs and symptoms of poor oxygen absorption. Staff interviews stated the resident was not alert, oriented, or verbal, and that the resident frequently pulled the tubing off, requiring frequent rounds and repositioning of the nasal cannula.
Controlled Substance Counts Were Inaccurate on a Medication Cart
Penalty
Summary
Narcotics/controlled substances were not reconciled for one medication cart observed in the facility. During review of Medication Cart #2, the narcotic count was inaccurate for Resident #127’s clonazepam 1 mg oral tablet and Resident #255’s lacosamide 100 mg oral tablet. The narcotic count sheet showed the last clonazepam tablet had been signed out as given at 10:00 PM on 09/16/25 with 19 tablets remaining, but the bingo card/packet count was 18. For lacosamide, the count sheet showed the last tablet had been signed out as given at 6:39 PM on 09/16/25 with 56 tablets remaining, but the bingo card/packet count was 55. The LPN acknowledged the discrepancies and stated she forgot to sign out the medications and was trying to sign them out before surveyors reached the cart. She then signed out the lacosamide tablet as given on 09/17/25 at 9:30 AM. Review of the EMAR showed Resident #127’s clonazepam 1 mg tablet and Resident #255’s lacosamide 100 mg tablet were each given on 09/17/25 at 9:00 AM. The LPN stated the facility’s policy is to sign out narcotic medications immediately after removing them from the bingo card and document them as given after the resident takes the medication. The DON stated that on 09/16/25 the facility had started Performance Improvement Plans for concerns including medication administration procedures and signing out controlled substances.
Infection Control Failure With Respiratory Equipment Stored Uncovered
Penalty
Summary
The facility failed to follow infection prevention and control procedures for two residents when respiratory equipment was observed stored at the bedside without protective covering. Resident #209, who had diagnoses including Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia, was observed in bed awake with oxygen running at 2 Lpm and an Incentive Spirometer on the bedside table with no protective covering. Resident #302, who had diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, was observed in bed awake with a BIPAP machine on the bedside table with no protective covering. On later observations, the Incentive Spirometer for Resident #209 and the BIPAP machine for Resident #302 were each seen in a resealable plastic bag dated 09/17/25. Staff interviews stated that respiratory equipment not in use is stored in dated resealable plastic bags and that the bags are changed weekly and as needed. The Unit Manager, when shown photographic evidence, stated that respiratory equipment is stored in a dated resealable plastic bag and changed weekly, and that the date on the bag is the date it was changed.
Inaccurate MDS Coding for Wander/Elopement Alarms
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents who were observed wearing electronic wander/elopement alarm devices as ordered by their physicians and documented in their care plans. Despite the presence of these devices and ongoing orders for their use, the Annual MDS assessments for both residents indicated that the devices were not used. Both residents had severe cognitive impairment, as evidenced by low Brief Interview for Mental Status (BIMS) scores, and were identified as being at risk for elopement or wandering due to dementia and impaired safety awareness. The care plans and physician orders specifically required the use and regular checking of the electronic wandering devices, which were observed in place during the survey. The deficiency was further confirmed through staff interview, where the MDS Coordinator acknowledged that the wander alert devices should have been coded in Section P of the MDS but were omitted due to oversight. Facility policy requires comprehensive and accurate MDS assessments in accordance with federal guidelines, but this was not followed in these cases. The inaccurate coding resulted from a failure to properly document the use of the electronic wander/elopement alarms on the MDS, despite clear evidence of their use and physician orders in the residents' records.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered by a physician for two residents, leading to deficiencies in pharmaceutical services. For Resident #6, a discrepancy was observed in the administration of Lactulose. The medication was administered at 15 ml, while the physician's order specified 10 ml daily. This error was identified during a medication administration observation and confirmed through interviews with the RN and the Director of Nursing (DON). The DON acknowledged the error, stating that the order should have been 10 ml daily, and an incident report was completed. Resident #6 was not harmed by this discrepancy. For Resident #1, there was a failure to administer Midodrine Hydrochloric Acid as ordered. The physician's orders required the medication to be given every eight hours via PEG tube for hypotension, with specific instructions to monitor vital signs. However, nursing notes revealed that the medication was not administered as scheduled, and the resident experienced high blood pressure during the shift. The DON explained that the facility does not have standard parameters for medications affecting blood pressure unless specified by the physician. The staff pharmacist confirmed that routine orders for Midodrine typically do not include parameters, except for contraindications like persistent supine hypertension. The facility's policy on medication administration emphasizes that medications should be administered as prescribed and in accordance with good nursing practices. However, the discrepancies in medication administration for both residents indicate a failure to adhere to these guidelines. The facility's medication distribution system is designed to ensure safe administration, but the errors in following physician orders for Resident #1 and Resident #6 highlight lapses in this system.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 is no longer at the facility. Resident #6's order was corrected. The physician was called and was advised of the incorrect dosage being administered, and no new orders were given. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken? All residents with orders were reviewed; any deficiencies found were corrected immediately. An audit was conducted which reviewed a sample of new orders for accurate transcription, and if any deficiencies were found, they were addressed immediately. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur; and? Standard parameters will be established through the therapeutic and pharmacy committee. All nursing staff will be educated on utilizing the standard parameters for orders, unless the physician ordered otherwise. An audit will be conducted to review orders daily by the nurse managers and pharmacist for 7 days, then weekly for 30 days, and then monthly for 3 months. If any deficiency is found, it will be corrected immediately. Nursing staff will be educated on accurately administering medications per physician's orders by following the Five Rights. A sample of new orders will be randomly audited on all units by the unit manager or designee daily for 7 days, then weekly for 30 days, and then monthly for 3 months. Additionally, the pharmacy representative will be conducting random medication administration pass observations weekly for 3 months; if any deficiencies are observed, education will be provided to the nurse immediately. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? This corrective action plan will be monitored through a dedicated PIP, and nursing home leadership will report findings to the monthly Quality and Risk Management committee. The committee will also evaluate the need for extended audits and further education, if necessary, after 90 days.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled in accordance with professional principles. During an observation of medication administration on the 2nd floor, a Licensed Practical Nurse (LPN) left a medication cart unlocked and unattended while using the telephone at the nursing station. A medical ointment was also found on top of the cart, which the LPN admitted should have been stored in the treatment cart. The LPN acknowledged that the cart should have been locked when unattended, even if it was within sight. Additionally, a discrepancy was noted between the labeled orders and the Electronic Medication Administration Record (EMAR) during a medication administration observation with a Registered Nurse (RN). The RN administered 15 ml of Lactulose solution as documented in the EMAR, while the Lactulose bottle was labeled to administer 30 ml daily. The facility's policy on medication storage, dated April 2018, states that medications and biologicals should be stored safely, securely, and properly, accessible only to authorized personnel.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by the deficient practice. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken? Alt medication carts were audited for medications left unattended, and carts left opened at the time, no other deficiencies were found at the time. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur? All nurses will be educated on locking their medication carts, and ensuring no medications are left unattended. Random audits will be conducted weekly by the Pharmacy representative and/or designee. Any deficiency found will be addressed immediately. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? This corrective action plan will be monitored through a dedicated PIP and nursing home leadership will report findings to the monthly Quality and Risk Management committee. The committee will also evaluate the need for extended audits and further education, if necessary, after 90 days.
Medication Administration Deficiency in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered by a physician for two residents, leading to a deficiency in compliance with pharmacy policies and procedures. For one resident, a registered nurse administered 15 ml of a medication, despite the physician's order indicating a dosage of 10 ml daily. This discrepancy was noted during an observation of the medication administration process, and the nurse referred to a physical chart that confirmed the physician's order for a lower dosage. The Director of Nursing later clarified that the order should have been 10 ml daily, and an incident report was completed. Another resident experienced a failure in medication administration when a scheduled medication for high blood pressure was not administered. The resident's son expressed concern about the medication causing low blood pressure, and the nurse contacted the physician to discuss the issue. The physician then ordered a reduced dosage of 2.5 mg daily, which the son agreed to. The resident required substantial assistance for daily activities and had a history of hypertension, which was relevant to the medication management. The facility's policy on medication administration emphasizes that medications should be administered as prescribed and in accordance with good nursing practices. However, the incidents involving these two residents demonstrate a failure to adhere to these standards, resulting in the administration of incorrect dosages and missed medications. These deficiencies were identified through observations, record reviews, and interviews with staff members.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 is no longer at the facility. Resident's #6 order was corrected. The physician was called and was advised of the incorrect dosage being administered, and no new orders were given. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken? All resident's with orders were reviewed, any deficiency found were corrected immediately. An audit was conducted which reviewed a sample of new orders for accurate transcription and if any deficiencies were found, they were addressed immediately. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur? Standard parameters will be established through the therapeutic and pharmacy committee. All nursing staff will be educated on utilizing the standard parameters for orders, unless, the physician ordered otherwise. An audit will be conducted to review orders daily by the nurse managers and pharmacist for 7 days, then weekly for 30 days and then monthly for 3 months. If any deficiency is found, it will be corrected immediately. Nursing staff will be educated on accurately administering medications per physicians orders by following the Five Rights. A sample of new orders will be randomly audited on all units by the unit manager or designee daily for 7 days, then weekly for 30 days, and then monthly for 3 months. Additionally, the pharmacy representative will be conducting random medication administration pass observations weekly for 3 months; if any deficiencies are observed, education will be provided to the nurse immediately. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? This corrective action plan will be monitored through a dedicated PIP and nursing home leadership will report findings to the monthly Quality and Risk Management committee. The committee will also evaluate the need for extended audits and further education, if necessary, after 90 days.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled in accordance with professional principles. During an observation of medication administration, a Licensed Practical Nurse (LPN) on the 2nd floor left a medication cart unlocked and unattended while using the telephone at the nursing station. The LPN acknowledged that the cart should have been locked when unattended, even though it was within sight. Additionally, a medical item was left on top of the cart, which should have been stored in the treatment cart. Another incident involved a Registered Nurse (RN) administering medication on the 2nd floor. The RN administered 15 ml of a solution as documented in the Electronic Medication Administration Record (EMAR), despite the bottle being labeled to administer 30 ml daily. This discrepancy between the labeled orders and the EMAR indicates a failure to follow proper medication administration protocols. The facility's policy on medication storage emphasizes that medications and biologicals should be stored safely and securely, accessible only to authorized personnel.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No residents were affected by the deficient practice. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken? All medication carts were audited for medications left unattended, and carts left opened at the time, no other deficiencies were found at the time. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur? All nurses will be educated on locking their medication carts, and ensuring no medications are left unattended. Random audits will be conducted weekly by the Pharmacy representative and/or designee. Any deficiency found will be addressed immediately. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? This corrective action plan will be monitored through a dedicated PIP and nursing home leadership will report findings to the monthly Quality and Risk Management committee. The committee will also evaluate the need for extended audits and further education, if necessary, after 90 days.
Failure to Complete Self-Administration of Medication Assessments
Penalty
Summary
The facility failed to complete a self-administration of medication assessment for two residents, leading to unauthorized medications being kept at their bedsides. Resident #294 was observed with a blue spray bottle labeled Immune Support Bio-active silver hydrosol at their bedside. The resident had no cognitive impairment and required substantial assistance for daily activities. However, there was no physician's order or self-administration assessment on file for this medication. Staff A, RN, was unaware of the resident's ability to self-medicate and removed the medication upon discovery. Similarly, Resident #648 was found with a box of Diclofenac Sodium Topical Gel 1% ointment and a bottle of Valerian Extract supplement at their bedside. This resident had moderate cognitive impairment and required assistance with daily activities. Although there was a physician's order for the Diclofenac Sodium, there was no order for the Valerian Extract, and no self-administration assessment was on file. Staff B, RN, was also unaware of the resident's ability to self-medicate and removed the medications upon discovery. Both incidents highlight the facility's failure to adhere to its policy requiring a self-administration assessment and physician's order for residents to keep medications at their bedside.
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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 | 2.3 mi | ★★★★★ | 1 | 0 |
| Jackson Gardens Health And Rehabilitation Center | 2.4 mi | ★★★★★ | 7 | 0 |
| Unity Healthcare And Rehabilitation Center | 2.5 mi | ★★★★★ | 1 | 0 |
| Miami Shores Nursing And Rehab Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Azure Shores Rehab | 2.9 mi | ★★★★★ | 13 | 0 |
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