Jackson Memorial Perdue: Narcotic Count Errors - FL
Federal inspectors visiting Jackson Memorial Perdue Medical Center on April 27, 2026, found exactly that problem on the North Wing's Red Medication Cart. Two residents. Two narcotics. Two counts that didn't add up.
The first involved Resident 97, who was prescribed Tramadol HCL 50 milligram tablets by mouth every 12 hours for non-acute pain. The narcotic accounting log said 22 tablets remained. The medication bingo card — the physical blister pack used to dispense the pills — held 21. One tablet unaccounted for in the paperwork.
The second was more striking. Resident 109 was receiving Oxycodone-Acetaminophen 5/325 milligram tablets through a gastric tube every 12 hours, also for non-acute pain. The narcotic log recorded a balance of 52 tablets. The bingo card had 51.
Inspectors conducted the review with Staff F, a registered nurse assigned to the North Wing's Red Cart, beginning at 11:00 AM. By 11:13, Staff F was explaining the facility's own procedure: when a controlled medication is removed from the bingo card, the nurse is supposed to record the time in the computer and sign the log immediately, noting how many pills remain.
Two minutes later, at 11:15, the North Wing Unit Manager, identified in the report as Staff D, RN, described the training she said she gave nursing staff. "I trained nursing staff to sign the narcotic book at the beginning of the shift and at the end making sure the paper matches the bingo card," she told inspectors. "If a nurse pulls a controlled medication, they sign the book at the time the medication is pulled."
That afternoon, at 2:45 PM, the Director of Nursing said the same thing in slightly different words: nurses must sign at the time a pill is removed to keep the reconciliation form accurate.
Three staff members, three consistent explanations of what the process is supposed to be. And still, the counts were wrong.
The facility's own written policy on controlled medications, dated November 19, 2025, is unambiguous. When a controlled medication is administered, the licensed nurse must immediately enter the date and time, the amount given, and their signature — completed after the medication is actually administered. Not at the end of the shift. Not when it's convenient. Immediately.
Jackson Memorial Perdue had six medication carts in operation at the time of the inspection. Inspectors reviewed three of them. The discrepancies appeared on one: the North Wing's Red Cart.
The inspection report rated the violation as causing minimal harm or potential for actual harm, affecting few residents. CMS assigned it the lower end of its deficiency scale. But the significance of controlled substance accounting isn't measured only in the severity of any single discrepancy. Opioids are among the most tightly regulated medications in any care setting precisely because the consequences of diversion — theft by staff, substitution of pills, systematic skimming — can be invisible until the losses become too large to hide behind a one-tablet gap.
A log that says 52 when the card holds 51 could mean a documentation error. It could mean a nurse pulled a pill and forgot to sign. It could mean something else. The accounting system exists so that facilities, regulators, and families don't have to guess.
Resident 109 receives oxycodone through a gastric tube. They cannot swallow. They depend entirely on staff to deliver the medication correctly, document it accurately, and account for every tablet. The log said they had 52. They had 51.
Nobody has explained publicly where that tablet went.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Jackson Memorial Perdue Medical Center from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
JACKSON MEMORIAL PERDUE MEDICAL CENTER in CUTLER BAY, FL was cited for violations during a health inspection on April 30, 2026.
Federal inspectors visiting Jackson Memorial Perdue Medical Center on April 27, 2026, found exactly that problem on the North Wing's Red Medication Cart.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.