Miami Springs Nursing And Rehabilitation Center

F-F641-Accuracy of Assessments related to

the facility's failure to accurately code the Minimum Data Set (MDS);

F-F812-Food Procurement Store/Prepare/Serve/Sanitary; due to the facility's failure to store food under sanitary conditions related to no thermometer observed inside the One North Station Pantry snack/nourishment freezer on the residents' unit, failed to ensure the proper temperature level for washing the dishes and utensils on the operable high temperature dish machine's tank temperature gauge and

F-F867 Quality Assurance and Performance Improvement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 106128 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106128 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166

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)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 31581 potential for actual harm Based on observations, interviews and record review the facility failed to ensure the high temperature dish Residents Affected - Some machine wash cycle was working properly. This has the potential to affect 176 out of 185 residents who eat orally residing in the facility at the time of the survey.

The findings included:

Record review of the Refrigerator/Freezer/Dishwasher Logs Policy and Procedure (revision date February 2024); Policy Statement-The temperature of the refrigerators and freezers will be recorded twice a day. Temperatures found not to be at the designated level will be reported to the Director of Nutritional Services or supervisor immediately. Temperatures will be recorded on a log; Procedure: 2) Dishwasher, a) While the dishwasher is running, with a rack going through it, the temperature of the wash tank and rinse tank will be recorded. Temperatures will be recorded for each meal, b) The Wash tank should be 140-160 degrees Fahrenheit (F), or as specified by the manufacturer and d) Any temperatures recorded outside the acceptable levels shall be reported to the supervisor immediately. Maintenance will be notified.

Review of the Dish Machine Temperature Log Policy and Procedure (no written date noted); Purpose-To ensure that dishware and utensils are sanitized effectively, the facility will monitor and document dish machine temperatures at every meal service in accordance with state and federal sanitation guidelines; Policy: Food and Nutrition Services staff will monitor and document the dish machine's wash and final rinse temperatures for each meal. Any discrepancies or equipment malfunctions will be addressed immediately to maintain sanitation compliance; Procedure: 2) At each meal service, dishwashing staff will: Observe and document the wash temperature, which must reach a minimum of 150 degrees F.

Review of the manufacturer temperatures for high temperature dish machine operating temperatures were documented: Wash 150-160 degrees Fahrenheit (F); Pumped Rinse 160 degrees F and Final Rinse 180-195 degrees F.

Observation of the high temperature dish machine on 5/07/25 at 10:04 AM with Staff B, Dietary Aide and the Training Center Account Manager revealed wash dial was at 110 degrees F and the final rinse dial was at 180 degrees F. Staff B, Dietary Aide revealed the wash temperature should be at 160 degree F and that she couldn't see the wash dial to read it. Staff B, Dietary Aide continued to place several more trays with dishes to be washed through the dish machine and the wash dial did not move, it stayed at 110 degrees F and the final rinse dial was at 180 degrees F. Several more cycles were conducted and the wash dial stayed at 110 degrees F and the final rinse dial was at 180 degrees F. The Training Center Account Manager revealed the wash temperature should be 150-160 degrees F. The Training Center Account Manager stopped the dish machine and called the service tech company to come to the facility and service the dish machine. She instructed the dietary staff to use disposable wear for feeding. Photographic evidence submitted.

Review of the Dish Machine Log documented for the month of May 7, 2025 documented the wash temperature was 160 degrees F and the final rinse was 180 degrees F for breakfast. Photographic evidence submitted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 106128 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106128 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Miami Springs Nursing and Rehabilitation Center 201 Curtiss Pkwy Miami Springs, FL 33166

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)

F 0908 Observation and interview on 5/07/25 at 12:17 PM, with the dish machine technician. He was observed servicing the dish machine. He stated, The thermostat was low on the wash tank. That is why it was at 110 Level of Harm - Minimal harm or degrees F. The temperatures should be 160 degrees F. I reset the temperature. potential for actual harm

Review of the Dish machine Repair Company Correspondence dated 5/08/25 documented the following: Residents Affected - Some Dish machine was checked and tested . Temperature on wash tank was low. Thermostat needed to be reset. Reason: Electrical activity in building. Wash tank temperature-165 degrees F. Temperature reset.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 106128