Health inspection·September 26, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review facility failed to follow a nutritional care plan for one (Resident #95) out of one sample resident, as evidenced by it was observed that Resident #95 was provided with a ham and cheese sandwich before leaving for dialysis. This meal was not consistent with the prescribed pureed diet, posing potential risks to Resident #95's health and wellbeing. There were 20 residents receiving pureed diets at the time of survey. The findings included: On 9/26/25 at 4:22 AM Resident #95 was observed in bed with no apparent distress.Observation on 9/26/25 at 4:25 AM at the first-floor nursing station revealed a transparent bag labeled with Resident #95's name and room number that contained a ham and cheese sandwich and applesauce (photo evidence).Interview on 9/26/25 at 4:33 AM Staff B, Registered Nurse (RN) was asked about Resident # 95 ‘s snack of ham and cheese sandwich and applesauce provided for the resident to take to dialysis; Staff B replied: This resident has been assessed, is waiting for pick up and always goes with a snack of sandwich and applesauce. On 09/26/25 at 4:58 AM, transportation arrived to pick up Resident#95.On 9/26/25 at 5:11 AM, the Assistant Director of Nursing (ADON) and Staff B, RN, were asked if it is okay for Resident #95 to leave with a sandwich despite the ordered pureed diet. The ADON replied: It is okay for the resident [Resident #95] to eat a ham and cheese sandwich because it can be mechanical soft.On 9/26/25 at 5:15 AM Resident #95 had already left the facility with the ham and cheese sandwich and applesauce that was provided.Interview on 9/26/25 at 6:30 AM, the Director of Nursing (DON) was asked if it is okay for Resident #95 who has an ordered pureed diet to be provided with a sandwich to take to dialysis; the DON replied: I will get back to you on that. On 9/26/25 at 6:45 AM, the Dietician was notified about identified diet concern and stated, A sandwich is not considered pureed.[Resident #95] used to be on a regular diet, and I will check with the Speech therapist to see if it is ok to send a sandwich.On 9/26/25 at 6:56 AM, the DON presented a transparent bag with Resident #95's name that contained a ham and cheese sandwich and applesauce and stated: We got the snack from the Dialysis center and replaced it with applesauce.Observation on 9/26/25 at 10:40 AM, Staff C, Speech therapist (ST), conducted a trial feeding of a ham sandwich with Resident #95. After some difficulty in following directions the therapist placed a small piece of bread into Resident #95's mouth and the resident began chewing. The therapist encouraged Resident #95 to swallow . After failing attempts to swallow, the Speech Therapist concluded that it was not safe for Resident #95 to eat sandwiches due to impaired cognition or physical tiredness from dialysis.Record review of a demographic sheet revealed Resident #95 was admitted on [DATE] with diagnosis that included: End Stage Renal Disease.Record review revealed the 5-day Medicare Minimum Data set (MDS) reference dated 9/11/25 revealed Resident #95 had a Brief Interview of Mental Status score of 8, indicating moderate cognitive impairment, required partial/moderate assistance for eating, received a mechanically altered and therapeutic diet, and held food in mouth/cheeks or had residual food in mouth after meals.Record review of a (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 6 Event ID: 106007 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 106007 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Floridean Health & Rehabilitation Center 47 NW 32nd Place Miami, FL 33125 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)