Health inspection·April 4, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to accurately code the Minimum Data Set (MDS) Assessment Section 0 for one (Resident #136) out of four residents reviewed for resident assessment. There were 166 residents residing at the facility at the time of the survey. Residents Affected - Few The findings included: Record review of Resident #136's admission Minimum Data Set (MDS) dated [DATE] Section O for Special treatments and procedures documented that the resident did not receive any special treatments or procedures. Review of the Physician's Orders Sheet for April 2024 revealed Resident #136 had orders that included but not limited to: Suction Tracheostomy (Trach) as needed and every shift, Trach care every shift and as needed, and Fraction of inspired oxygen (FIO2) at 30% via trach collar every Shift. Further review of the medical records for Resident #136 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia and Encounter for attention to tracheostomy. Record review of Resident #136 's Care Plans dated 03/13/2024 documented: Resident has potential for complications related to tracheostomy. Interventions include but are not limited to: Assess lung sounds every shift. Report any wheezes, crackles, or decreased breath sounds. Assist resident to turn, cough, and deep breath every 2-3 hours and as needed. Monitor and report signs of localized infection (localized swelling, redness, pain or tenderness, heat at the infected area, purulent drainage, loss of function). Monitor and report signs of systemic infection (fever, malaise, change in mental status, anorexia, nausea, headache, lymph node tenderness/enlargement). Provide tracheostomy care every shift and as needed. Provide oral hygiene every shift. Use principles of infection control and universal/standard precautions. Interview 04/04/2024 at 07:33 AM. Registered Nurse, Minimum data Set Coordinator (Staff B), was asked about the resident's MDS admission Assessment section O pertinent data. Staff B stated: I missed that section somehow and I will do a correction right away, we have two MDS coordinators and we have our units that we are responsible for, I am assigned units-east 1, west 2 and south 2, and I am assigned to this resident. When I do my assessment of a resident, I observe the resident, I talk to the staff the CNAs (Certified Nursing Assistants) and the Nurses about the resident before I complete the MDS assessment for the particular resident. Review of the facility's policy and procedure titled Nursing/Treatment-Wound Dressing Changes dated (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 9 Event ID: 105392 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 105392 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jackson Memorial Long Term Care Center 2500 NW 22nd Ave Miami, FL 33142 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)