Based on observation, record review, and staff interviews, the facility failed to ensure that the facility's only freezer was operational to ensure that frozen foods were kept frozen solid until ready for the cooking process. The failed practice impacted raw meats and food items intended for use to prepare meals for 40 of 59 residents receiving oral nutrition from October 8 through 13, 2017. The findings include: An Immediate Jeopardy (IJ) identified at 42 CFR §483.90 (d)(2)(e) Physical Environment Space and Equipment; F-456 Maintain all mechanical, electrical, and patient care equipment in safe operating condition. The facility's Administrator provided a letter documenting a corrective action plan to include staff training and competency, policy revisions and equipment repairs. …
F456
Environmental Deficiencies
Keep all essential equipment working safely.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
The harm level
How severely F456 is cited
0.0% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D1100.0% | E— | F— |
| No harm, potential for minimal | A— | B— | C— |
In the surveyor’s words
What an F456 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observation, interview and record review, the facility failed to maintain all patient care equipment in safe operating condition. Resident #1 had an assist bar attached to her bed for repositioning. During a transfer, resident #1 sustained a laceration to her left lower leg that required 26 sutures. One of the two ends at the bottom of the assist bar did not have a rubber [MEDICATION NAME] and the metal edge was exposed. This deficient practice placed 11 residents with assist bars attached to their beds on three of four units at risk of physical harm. Findings include: Review of the Admission Record dated 04/11/17 revealed resident #1 was a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. …
Based on observation, interview, and record review the facility failed to ensure resident equipment was in safe operating condition when: 1. Wanderguards (bracelet secured to ankle that cannot be removed by resident, alarmed if the resident left the facility and would continue to alarm until a code was put into the device by staff) for one of nine sampled residents (Resident 9) and three out of sample residents (Residents 12, 16, and 17) were not: a. Monitored and were used beyond their recommended expiration date. b. Replaced when expired This resulted in four Wanderguards to be used beyond their expiration date and not replaced due to the Wanderguard vendor not getting paid. 2. …
Based on observation of the dish machine on (MONTH) 1, (YEAR), and based on interview of a maintenance worker, it was determined that administration failed to assure that this piece of essential mechanical equipment was being properly operated and maintained. The findings included: On (MONTH) 1, (YEAR), this surveyor conducted an inspection of the main kitchen. During that tour, observation of the dish machine revealed that it did not reach a minimum temperature of 180 degree Fahrenheit during the final rinse cycle as required. Interview of a maintenance worker revealed that the machine had been experiencing issues with the booster heater and that internal fuses in the booster heater were repeatedly failing. …
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