Health inspection·February 27, 2026

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviewed and interviews, the facility failed to provide adequate supervision to prevent falls for one resident (Resident #1) out of three sampled residents reviewed for accidents and falls during a complaint investigation survey. Resident #1 a newly admitted , vulnerable and cognitively impaired had an assigned one to one (1:1) sitter was left unsupervised exited the facility through an emergency exit door descending a flight of stairs. Staff found Resident #1 at the bottom of the stairs (8 steps total) with abrasions to the bridge of the nose, right hand, and forehead. There were 172 residents residing in the facility during the survey. The findings include:Observational tour on 02/26/2026 starting at 8:18 AM of the location of the incident involving Resident #1 revealed the resident exited the facility through the South Two Emergency Exit located approximately 30 feet from the resident's room.Record Review Resident # 1's clinical records revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to Fracture of unspecified part of left clavicle with routine healing, Traumatic Brain Injury (TBI), Impulse Disorder, Generalized Anxiety Disorder, Unspecified, and Polyneuropathy. Review of Fall assessment dated [DATE] timestamped 4:01AM revealed a Fall Risk Assessment score of 10 which indicated the resident was at risk for fall.Review of Nursing Progress Note dated 02/06/2026 timestamped 11:43 AM indicated:Resident noted with multiple trips to bathroom with watery stools. Resident with unsteady gait, and confusion. Resident on hourly rounds. Supervisor made aware and awaiting order for 1:1 supervision. Writer and ARNP (Advanced Registered Nurse Practitioner) at nurses' station working on new orders that were received from Psychiatrist regarding resident. At about 10:30 exit door alarm started to alarm, and staff was alerted to assist with resident that exited door. Writer entered area and observed resident sitting at the bottom of the steps. As writer assisted to help resident to and standing position with another staff resident noted with bleeding from right side of forehead and bridge of nose. Resident was able to walk back upstairs with two persons assist back to room. ARNP on unit at time of incident head-to-toe assessment done. Resident with 2 abrasions to right side of forehead, 1 abrasion to bridge of nose, 1 open area to right hand palm area, 1 open area to right hand 4th digit. MD (Medical Doctor) notified and gave order to transfer resident to [local hospital emergency room] 911 called.fire rescue attendants arrived in unit. Resident left unit via stretcher. Review of Physician Orders for Resident #1 revealed an order dated 02/05/2026 for 1:1 supervision to ensure safety and support cognitive recovery, and an order dated 2/05/2026 to maintain fall precautions every shift. Order dated 02/06/2026 to transfer resident to [local hospital] emergency room status post fall with abrasion to right side of forehead, nose and right hand.Record review of a Hospital Summary dated 02/07/2026 timestamped 5:39 AM revealed Computed Axial Tomography Scan (CT) results indicated no other acute traumatic injuries noted. Record review of Fall Care Plan initiated on 02/06/2026 and revised on 02/06/2026 revealed Resident #1 had potential for falls related to use of psychotropic (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 2 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 02/27/2026 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)