Miami Jewish Health Systems, INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to secure residents' confidential information on two ([NAME]-1st floor, Medication Cart 1 and 5th floor, Medication Cart 2) out of four medication carts: as evidenced by unattended Medication Carts noted with unlocked computer screens displaying residents' confidential information during medication administration. There were 288 residents residing in the facility at the time of the survey.The findings included: Observation on 09/16/2025 at 9:47 AM, on the 5th floor, revealed Medication Cart 2 was left unattended and the computer's screen unlocked with visible resident information. (Photographic evidence). The Surveyor notified Staff C, Registered Nurse (RN) of the identified concern. Staff C, RN revealed she did not realize she had left the computer screen open. On 09/16/2025 at 10:15 AM, observation on the 1st floor revealed Medication Cart 1 unattended and the computer screen unlocked with visible resident information. (Photographic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure oxygen therapy was delivered as prescribed for one (Resident # 55) out of one sampled resident who has a primary diagnosis of Acute Respiratory Failure. As evidenced by the resident's nasal canula (NC) was not in nostrils. The findings included.Observation on 09/16/2025 at 11:07 AM, Resident #55 was in bed with eyes closed, Oxygen (02) running at two (2) Liters per Minute (LPM) via Nasal Canula (NC), NC not in resident's nostrils. The surveyor requested to see the assigned nurse in resident's room.On 09/16/2025 at 11:14 AM Licensed Practical Nurse (Staff F), positioned the 02 tubing in the resident's nostrils, checked the resident's oxygen saturation on the right index finger, the reading was100.On 09/17/2025 at 10:53 AM, Resident #55 was observed in bed, receiving morning care, 02 running at 2 LPM via NC, nasal tubing position correctly in nostrils.During observation on 09/18/2025 at 10:00 AM, Resident #55 noted in room receiving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, records reviewed and interviews, the facility failed to ensure narcotics/ controlled substances were reconciled for one ([NAME] 3, Medication Cart #2) out of ten medication carts observed in the facility. There were 288 residents residing in the facility at the time of this survey.The findings include. On 09/17/2025 at 10:00 AM during the narcotic count and review of [NAME] (3) Medication Cart #2 with Licensed Practical Nurse (Staff I), the narcotic count was inaccurate for Resident # 127's Clonazepam oral tablet 1milligrams (mg). The narcotic count sheet revealed that the last tablet was signed out as given at 10:00 PM on 09/16/25 and the remaining tablets noted as 19. The bingo card/packet count was 18. In addition, the narcotic count was inaccurate for Resident # 255's Lacosamide Oral Tablet 100 milligrams (mg) tablet. The narcotic count sheet revealed that the last tablet was signed out as given at 06:39 PM on 09/16/25 and the remaining tablets noted as 56. The bingo card/packet count…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to follow infection prevention and control procedures for two (Resident #209 and Resident #302) out of 35 residents sampled. As evidenced by Resident #209's Incentive Spirometer and Resident # 302's Bilevel Positive Airway Pressure (BIPAP) machine was observed stored at bedside with no protective covering. The findings include.During observation on 09/16/2025 at 11:47 AM Resident #209 was in bed awake, oxygen (02) running at two (2) Liters per minute (Lpm), Incentive spirometer stored on bedside table with no protective covering (Photographic evidenced).Observation on 09/17/2025 at 11:00 AM and on 09/18/2025 at 01:27 PM the Incentive Spirometer was noted on the bedside table in a resealable plastic bag dated 09/17/25.Review of Resident # 209 medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to Chronic Obstructive Pulmonary disease, Chronic Respiratory Failure with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for two (Residents #5 and #6) out of three residents sampled, as evidenced by Resident # 5 and Resident # 6 had wander/elopement alarm devices on their left ankle as ordered. However, the Annual MDS indicated the devices were not used. There were 306 residents residing at the facility at the time of the survey. The findings included: Resident #5: On 06/02/2025 at 12:40 PM Resident #5 was observed in the dining room, sitting in her wheelchair eating independently. Review of Resident #5's medical records revealed the resident was initially admitted to the facility on admitted to the facility on [DATE]. Clinical diagnoses include Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance and Alzheimer's disease. Review of Resident # 5's Physician's Orders Sheet and Electronic Treatment Administration Records for June 2025 revealed an order with start date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews facility failed to administer medications as ordered by a physician in accordance with professional standards for two residents (Resident #1 and Resident #6) out of four sampled residents as evidenced by staff failed to administer an accurate dose of a laxative for Resident #1 and failed to administer a blood pressure lowering medication as ordered for Resident #1. The findings included: Observation on 2/25/25 at 9:12 AM of Resident # 6's medication administration being completed by Staff B, Registered Nurse (RN) revealed the medications administered by mouth included Lactulose 15 ml (milliliters). The label on the bottle of Lactulose read 30 ml daily by mouth (photographic evidence). Review of Resident #6's physician orders revealed order dated 2/21/25: Lactulose Oral Solution 10 gm/15 ml (grams/milliliters) directions: Give 15 ml by mouth in the morning for constipation. Record review of Resident #6's demographic sheet revealed the resident was initially…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review the facility failed to ensure drugs and biologicals stored and labeled in accordance with professional principles, as evidenced by one out of three medication carts sampled was left unlocked and unattended with a medical ointment on top of the cart; and discrepancy with labeled orders and Electronic Medication Administration (EMAR). The findings included: On 2/25/25 at 8:43 AM during observation of medication administration conducted by Staff A, Licensed Practical Nurse (LPN) on the 2nd floor, Staff A, LPN stepped away from the medication cart to use the telephone at the nursing station, leaving the medication cart unlocked and a medical ointment on top of the cart. When Staff A, LPN returned to the cart the surveyor asked Staff A,LPN about the protocol for securing medication and storing ointments; Staff A,LPN replied: The cart should be locked when I walk away. The reason I left the cart unlocked when I walked away was because I could still see the cart. It is not okay to leave the cart unlocked. Ointments are kept in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to complete a self-administration of medication assessment for two residents (Resident #294 and Resident #648) out of ten residents sampled as evidenced by an observation of a blue spray bottle labeled Immune Support Bio-active silver hydrosol at Resident # 294's and a box labeled Diclofenac Sodium Topical Gel 1 % ointment and a bottle labeled Valerian Extract supplement at Resident #648's. Both residents did not have a self-administration of medication assessment on file. There were 296 residents residing in the facility at the time of survey. On 05/06/2024 at 12:05 PM an observation was made of a blue spray bottle labeled Immune Support Bio-active silver hydrosol at bedside of Resident #294. On 05/06/2024 at 12:05 PM Staff A, Registered Nurse (RN) stated: I am the nurse assigned to [Resident #294]. I am not aware of [Resident #294] being able to self-medicate or keep medications at the bedside and I will follow up with the supervisor. Staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide assistance during dining observation for 1 (Resident #293) of 6 residents reviewed for nutrition. The findings included: In an observation conducted on 12/12/22 at 1:00 PM, Resident #293 was noted in her room with the lunch tray. The lunch tray was observed to be 100% untouched, and no staff was noted in the room. Continued observation at 1:25 PM showed no staff in the room assisting Resident #293 with her lunch meal. In an observation conducted on 12/13/22 at 8:03 AM, Resident #293 was noted in her room with the breakfast tray in front of her. The tray was set up, and some of the food was cut into smaller pieces, but no staff was noted in the room. It was noted that 50 % of the [brand] nutritional supplement was 50% consumed. The food on the tray was noted to be 100% untouched. At 8:17 AM, showed Staff in the room standing over Resident #293, asking her if she wanted to eat. At 8:18 AM, Staff noted walking out of the room, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide the correct food consistencies for the ordered Pureed diets during dining observations and the second tour of the main kitchen. This has the potential to affect 52 residents residing in the facility on a Pureed diet. The findings included: A review of the Nation Dysphagia Diet Pureed Nutrition Therapy dated September 24, 2019, which Staff E, Registered Dietitian provided, showed the following: Pureed diet is indicated for the resident who has difficulty chewing or swallowing food items and benefits from stricter modifications of food textures to provide foods that can be successfully and safely swallowed. This diet consists of foods that are easy to swallow because they are pureed, smooth, and lump-free, not firm or sticky_ Foods do not require any chewing and may be prescribed due to several medical conditions. In an observation conducted on 12/12/22 at 1:00 PM, Resident #751 was noted in her room with her lunch tray. Closer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.