Lorien Health Systems - Columbia

Based on record review and staff interviews, it was determined that the facility failed to ensure acceptable standards of practice to accurately reconcile controlled medications. During observation of the facility narcotic books, it was observed that 2 of 2 narcotic reconciliation were not documented per acceptable standards of practice during the annual survey.The findings include:Standard practice for narcotic reconciliation count is conducted at the end-of-shift with two licensed personnel, the on-coming licensed personnel and the out-going licensed personnel, count all controlled medications verifying the count accuracy and documenting their initials in the narcotic book. Reconciliation refers to a system of recordkeeping that ensures an accurate inventory of medications by accounting for controlled medications. The reconciliation process identifies loss or potential diversion of controlled medications so as to minimize the time between the actual loss or potential diversion and the time of detection and follow-up to determine the extent of loss. On 1/7/26 a record review of 2…

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 interview and record review, it was determined that the facility failed to provide an activity program according to the resident's comprehensive assessment and personal choice. This deficiency was evident for 1 of 4 residents (Resident #4) reviewed for activities during the survey.The findings include:On 1/6/26 at 9:45 AM, during an interview, Resident #4, who required ventilator assistance to aid respirations, reported a desire to have a wheelchair to go outside.On 1/8/2026 at 12:41 PM, review of admission material dated 2/24/25, Section F, revealed the resident was asked, How important is it to you to go outside to get fresh air when the weather is good? Continued review revealed that the resident responded that this was very important.On 1/8/2026 at 12:36 PM, review of Resident #4's progress notes under activities dated 2/24/2025 documented that the resident preferred individual activities and spending time outside.On 1/8/26 at 1:01 PM, the Activities Director, Staff #8, was interviewed. Staff reported that resident attendance was recorded for both group and one-on-one…

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 record review and interviews, it was determined that the facility failed to ensure physician orders were followed. This was evident for one (Resident #171) out of five residents reviewed for unnecessary medications.The findings include:Type 2 diabetes is a chronic condition that requires routine blood glucose monitoring and administration of prescribed medications to maintain blood sugar levels within a safe range. Failure to monitor blood glucose levels and administer ordered insulin can result in uncontrolled blood sugar levels and places a resident at risk for serious complications, including dangerously high or low blood sugar levels and long-term organ damage.On 1/14/26 at 10:07 AM, the surveyor conducted a record review of Resident #171's medical record and identified a diagnosis of Type 2 Diabetes Mellitus. Review of the Medication Administration Record (MAR) revealed the following physician orders:Novolog FlexPen (Insulin Aspart) 100 units/mL: Inject 3 units subcutaneously with meals for Type 2 diabetes. Hold Novolog if blood sugar is below 100. 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.

Based on observation, medical record review and interviews it was determined that the facility failed to ensure wound treatment was completed as ordered and that orders coincided with treatments being documented by the wound care physician. This was found to be evident for one (Resident #13) out of three residents reviewed for pressure ulcers during the survey.The findings include: Review of Resident #13's medical record revealed the resident was admitted in the spring of 2025 with a stage 2 pressure ulcer on the sacrum. The sacrum is located at the base of the spine.A stage 2 pressure ulcer involves partial thickness skin loss presenting as a shallow open ulcer.The resident has been seen weekly since admission by the wound physician. Starting on 7/18/25 the wound physician notes indicated the sacral wound was a stage 3 pressure ulcer.A Stage 3 pressure ulcer involves full thickness skin loss and subcutaneous fat may be visible.Review of the 9/5/25 wound physician note revealed the dressing used at that time was Collagen and Bordered dressing once daily, with Betadine to 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.

Based on medical record review, interview and observation it was determined that the facility failed to ensure an underweight resident was provided diet as needed. This was found to be evident for one (Resident #137) out of six residents reviewed for nutrition.The findings include: Review of Resident #137's medical record revealed a 9/4/25 dietitian note that indicated the resident was underweight with a current weight of 102 lbs. The dietitian recommended a regular consistency diet with double portions of vegetables and entree. Review of the 12/19/25 dietitian note revealed the resident weight was down to 94.6 lbs. On 1/7/26 at 1:29 PM surveyor observed the resident in bed, lunch tray was observed on the resident's overbed table but resident appeared to be asleep at this time. At 1:32 PM observation of the lunch tray, with the unit nurse manager #10, revealed rice and peas on the plate but failed to reveal a protein on the tray. The meal ticket revealed the resident should also have had 2 chicken salad sandwiches. There was no evidence on the lunch tray that the sandwiches were…

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 record review and interview it was determined that the facility failed to ensure pain management was provided in accordance with professional standards of practice. This was found to be evident for one ( Resident #137) out of three residents reviewed in relation to faciity reported incidents of injury of unknown origin.The findings include:Review of facility reported incident 2639787 revealed the facility reported an injury of unknown origin for Resident #137 on 10/9/26. The injury was a fracture to the right leg.Review of Resident #137's medical record revealed the resident diagnosis included, but was not limited to, diabetes, heart failure, end stage renal disease and memory deficit following a stroke. Review of the 10/6/26 primary care provider note revealed that the resident was in no acute distress that day, and the resident was able to move all extremities but with right sided weakness and muscle wasting. Review of the Treatment Administration Record for October 2026 revealed documentation that staff completed pain assessments every shift and the pain level was…

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 record review and interview, it was determined that the facility failed to have an effective process to ensure that pharmacy recommendations were reviewed by the resident's provider. This was evident for 1 resident (Resident #2) of 5 residents reviewed for unnecessary medications during the survey.Findings included:On 1/7/26 at 10:38 AM, the medical records of Resident #2 were reviewed. The review revealed that a pharmacist had reviewed the resident's medical records at admission. Further review failed to show documentation that the provider received the pharmacist's recommendations.On 1/7/26 at 2:00 PM, the Administrator provided the admission Pharmacy Review for Resident #2 dated 12/10/25. The Administrator confirmed that the review had not been uploaded to the resident's electronic health record or hard chart.On 1/7/26 at 2:00 PM, the admission pharmacy review revealed several recommendations. Review showed that the provider reviewed the document and ordered labs and an EKG (electrocardiogram). The pharmacy medication review was signed by the provider but was not dated.…

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 record review and interviews, it was determined that the facility failed to maintain a complete and accurate medical record. This was evident for 1(resident #202) out of 199 residents review during an annual survey.The findings include: On [DATE] at 10:17 AM, the surveyor completed a closed record review for Resident #202 who was deceased on [DATE], no hard copy medical record was available. The review revealed the Resident's MOLST form and death certificate were not in the electronic record even though the electronic record indicated see new MOLST on [DATE].Medical Orders for Life-Sustaining Treatment (MOLST) is a medical order form that relays instructions between health professionals about patient care. MOLST certified orders that were agreed to by a patient or a patient's health care agent as named in the patient's advance directive. MOLST determines resuscitation status and includes 8 other sections of treatment choices.Interview, on [DATE] at 11:09 AM, Medical Record Staff #7 responded that every…

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 pertinent document review and interviews, it was determined the facility failed to ensure that the appropriate party signed the arbitration agreement or that the resident received information and understood the arbitration agreement. This was evident for one of three residents reviewed for arbitration during a survey. The findings included:On 1/5/26 at 9:15 AM, during the entrance conference, the administrator reported that the facility had an arbitration agreement that was given to the resident upon admission. The administrator reported that admission to the facility was not dependent on signing the arbitration agreement. The administrator reported that the arbitration agreement was not binding. On 1/7/26 at 9:48 AM, the Chief Clinical Officer (Staff #20) was interviewed regarding the facility's arbitration agreement. Staff #20 reported that the agreement was voluntary and that residents had thirty days to rescind their signature after signing the arbitration agreement. In addition, Staff #20 reported…

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 medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #7, #19 & #23). This is evident for 3 of 5 residents reviewed for pressure ulcers during a complaint survey. The findings include: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). A deep tissue injury (DTI) is a unique form of pressure ulcer. 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 review of a facility reported incident, medical record review and interviews, the facility staff failed to ensure outside providers obtained consent from a resident's representative to perform a debridement on a resident's wound (Resident #9). This was evident for 1 of 24 residents reviewed during a complaint survey. The findings include: Review of facility reported incident 344184 on 9/22/25 revealed 2 nurse practitioners (Staff #26 & #27) sent from Resident #9's Assisted Living entered the facility on 5/29/25 and performed a debridement on Resident #9's right heel wound without consent from the Resident's representative. Review of Resident #9's medical record on 9/22/25 revealed the Resident was admitted to the facility on [DATE] following a hospitalization with a diagnosis to include Dementia. Dementia is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life. The facility staff assessed the Resident on 4/3/25 to…

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 review of facility documentation and staff interview, it was determined the facility failed to provide documentation that allegations of abuse were thoroughly investigated. This was evident for 1 (#12) of 10 residents reviewed for facility reported incidents during a complaint survey. The findings include: On 9/26/25 at 11:22 AM a review of facility reported incident 344173 was conducted and revealed Resident #12 alleged to the social worker that a geriatric nursing assistant (GNA) pushed his/her head on the bed during ADL (activities of daily living) care. Review of the facility documentation revealed a written statement from Social Worker #20 who documented that during the conversation that she had with Resident #12, Resident #12 stated that he/she felt the nurses did not care about him/her. Resident #12 stated that some were rough when providing treatment and stated that one nurse made the resident cry because she was not gentle with him/her. The first nurse was Staff #18 and the second one that pushed his/her head back was Staff #17. Review of statements from 3 other…

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 medical record review and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions. This was evident for 1 (#14) of 14 residents reviewed for complaints during a complaint survey.The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. On 9/24/25 at 10:30 AM a review of Resident #14's medical record revealed Resident #14 was admitted to the facility in December 2024 with diagnoses that included but were not limited to cardiac arrest which resulted in anoxic brain damage, asthma, and dependence on a ventilator. Review of Resident #14's weekly skin assessment sheets documented on 12/20/24 there was a DTI (deep tissue injury) to the left heel. Weekly skin sheets from 12/20/24 to 1/24/25 documented the DTI to the left heel and on 1/24/25 there was a Stage 2 pressure ulcer to the left ischium and a DTI to the right buttock. Review of Resident #14's care plans revealed a…

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 medical record review and interview, it was determined the facility failed to ensure residents received treatments per physician orders (Resident #18 and #19). This was evident for 2 of 24 residents reviewed during a complaint survey. The findings include: 1.Review of Resident #18's medical record on 9/22/25 revealed the Resident was admitted to the facility from the hospital on 7/14/24 with a diagnosis to include dermatitis. Dermatitis is a common condition that causes swelling and irritation of the skin. Review of Resident #18's July 2024 Treatment Administration Record (TAR) revealed on admission the Resident was being treated for the dermatitis by the facility staff through 7/30/24. Further review of Resident #18's medical record revealed she was seen and assessed by the Wound Doctor on 7/26/24 who diagnosed the Resident with fungal dermatitis and ordered Clotrimazole daily. Review of Resident #18's July TAR revealed the Resident received Clotrimazole until 7/30/24. The Resident was seen again on 8/2/24 and 8/9/24 by the Wound Doctor for the fungal dermatitis and stated…

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 medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to follow physician ordered parameters when administering blood pressure and diabetic medications. This was evident for 3 (#16, #17, #23) of 24 residents reviewed during a complaint survey. The findings include: 1.On 9/25/25 at 12:26 PM Resident #16's medical record was reviewed and revealed Resident #16 was admitted to the facility on [DATE] from an acute care facility for rehabilitation. Resident #16's diagnoses included but were not limited to encephalopathy, nonrheumatic aortic valve stenosis, atrial fibrillation, type 2 diabetes mellitus with diabetic peripheral angiopathy, heart failure, and end stage renal disease. Review of Resident #16's January 2025 physician's orders revealed the medication Carvedilol 6.25 mg. to be given twice per day for hypertension (high blood pressure). Carvedilol is a beta-blocker used to treat cardiovascular conditions…

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 record review and interview with the facility staff, it was determined that the facility failed to complete a performance review of every nurse aide at least once every 12 months. This was evident for 5 Geriatric Nursing Assistant, (GNA #26, GNA #27, GNA #28, GNA #29 and GNA #30) of the 5 GNAs reviewed for performance evaluations. The findings include: On 7/03/24 at 12:52 PM, review of staff personnel records revealed that GNA #26, GNA #27, GNA #28, GNA #29, GNA #30 had no performance evaluations. On 7/03/24 at 1:09 PM an interview with the Nursing Home Administrator (NHA) was conducted. She was asked to provide performance evaluations for GNA #26, GNA #27, GNA #28, GNA #29 and GNA #30. On 7/03/24 at 1:50 PM an interview with HR Director (Staff #31) and the NHA regarding employee performance evaluations was conducted. They both confirmed that they do not have performance evaluations for GNA #26, GNA #27, GNA #28, GNA #29 and GNA #30. They both stated the understanding that this was a deficiency.

Based on interview, observation and record review it was determined that the facility staff failed 1) to prevent bare hands contact of ready-to-eat food (toast). This was observed while conducting an in-room interview with resident #49, and 2) to ensure: kitchen staff use of hair coverings, clean and appropriate dating and storage of food items, maintenance of kitchen equipment, cold food storage free from ice accumulation, tray line accuracy, sanitary food prep surfaces free from personal items, and ensure monitoring of required dishwashing sanitization temperature levels. All residents have the potential to be affected by these practices. The findings include. 1) Resident #49 was interviewed on 6/21/24 at 8:49AM. At 8:49 AM GNA #2 knocked on the resident door and brought a covered plate into the room. She asked resident #49 if S/he wanted their toast buttered. Resident #49 agreed and GNA #2 picked up a half a slice of toast with her bare hand and proceeded to butter the bread with a knife. She placed the first half down and picked up the second half with her bare hand and buttered…

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 record review and interview it was determined that the facility failed to ensure all staff received training in effective communication. This was evident for all staff during the Extended Survey investigation portion of the recertification survey. The findings include: On 7/05/24 at 11:19 AM an interview with the Human Resources Director (Staff #31) was conducted. She brought the annual training plan that the facility's corporate office required to be completed by nurses and Geriatric Nursing Assistants (GNAs). It did not include any training about effective communication. Staff #31 also provided the training records for 4 GNAs (GNA #27, GNA #28, GNA #29, and GNA #30). On 7/05/24 at 12:20 PM in an interview with the Director of Nursing (DON) and the Chief Executive Officer (CEO), they provided training materials from the recent skills day. A review of the documents provided revealed that there was no training for effective communication. On 7/10/24 at 1:30 pm a record review of training records for GNA #27, GNA #28, GNA #29, and GNA #30 revealed that none of them had any…

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 record review and interviews it was determined that the facility failed to have a Behavioral Health Training Program. This was evident during the Extended Survey portion of the recertification survey. The findings include: On 7/05/24 at 11:19 AM an interview with the Human Resources Director (Staff #31) was conducted. She brought the annual training plan that the facility's corporate office required to be completed by nurses and Geriatric Nursing Assistants (GNAs). It did not include any information about a Behavioral Health Training Program. Staff #31 also provided the training records for 4 GNAs (GNA #27, GNA #28, GNA #29, and GNA #30). On 7/05/24 at 12:20 PM an interview with the Director of Nursing (DON) and the Chief Executive Officer (CEO), was conducted and they provided training materials from the recent skills day. There was no evidence of any Behavioral Health Training Program in the documents provided. On 7/10/24 at 1:30 pm a record review of training records for GNA #27, GNA #28, GNA #29, and GNA #30 revealed that none of them had any training for Behavioral…

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 medical record review and staff interview it was determined the facility failed to notify the resident/resident representative (RP) in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 4 (Resident #49, #74, #99, #131) of 6 residents reviewed for hospitalization during a recertification/complaint survey. The findings include: 1) During an initial screen of Resident #131 on 6/21/2024 at 2:54 PM by a surveyor, the resident stated that s/he was sent to the hospital for infection and saying crazy stuff last November/December. On 7/1/2024 at 11:50 AM, the surveyor went to interview the resident, but they were not in their room. On 7/1/2024 at 11:57 AM, an interview was completed with Licensed Practical Nurse (LPN #3) who stated that Resident #131 was sent out to the hospital a few days ago for a change in mental status. Regarding transferring residents out to the hospital, LPN #3 stated that she has never given a resident/resident representative (RP)…

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 medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed-hold policy upon transfer of a resident to an acute care facility. This was evident for 4 (Resident #49, #74, #99, #131) of 6 residents reviewed for hospitalization during a recertification/complaint survey. The findings include: The bed-hold policy describes the facility's policy of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. 1) During an initial screen of Resident # 131 on 6/21/2024 at 2:54 PM by a surveyor, the resident stated that s/he was sent to the hospital for infection and saying crazy stuff last November/December. On 7/1/2024 at 11:50 AM, surveyor went to interview the resident, but they were not in their room. On 7/1/2024 at 11:57 AM, an interview was completed with Licensed Practical Nurse (LPN #3) who stated that Resident #131 was sent out to the hospital a few…

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, medical record review, and staff interview, it was determined the facility staff failed to develop and initiate comprehensive person-centered care plans for residents residing in the facility. This was evident for 1 (# 131) of 2 residents reviewed for dialysis, 1 (Resident #163) out of 9 residents reviewed for unnecessary medications, 1 resident (Resident #83) of 1 residents reviewed for Rehabilitation and Restorative care during the recertification survey, and 1 (Resident #109) out of one resident reviewed for hospice during the facility's recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Hemodialysis or simply dialysis is a process of filtering the blood of a person whose kidneys are not working normally. An arteriovenous (AV) fistula is a connection that's made between an artery and a vein for dialysis access. A surgical procedure, done…

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 observation and interviews with residents, it was determined that the facility staff failed to treat residents with dignity and respect by leaving residents who needed assistance with dressing undressed. This was evident for 1 (Resident #61) of 4 residents reviewed for dignity during the survey. The findings include: On 6/20/24 at 9:40 AM, two surveyors entered Resident #61's room for an interview while the room door was wide open, and the curtain was not applied. Surveyors observed that the resident was not appropriately dressed; no gown or clothes worn, a gown placed on the top of his/her chest. Resident #61 reported, I messed up my clothes. Waiting for staff to bathe me. No one helped me for 40 minutes. The resident also mentioned that he/she preferred to have clothes on, but it was okay as long as no [opposite gender resident] came into his/her room. While surveyors were interviewing Resident #61 on 6/20/24 at 10:11 AM, an opposite-gender resident opened the door and tried to come in. On 6/24/24 at 12:59 PM, a second observation of Resident #61 noted that he/she was…

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 and interview with the facility staff, it was determined that the facility failed to provide an environment that was safe, clean and in good repair. This was evident in one room during the initial observation of the Renaissance 1 Medical Surgical Unit (MSU). The findings include: On 6/20/24 at 2:35 PM it was observed that in the bathroom of room [ROOM NUMBER], 2 ceiling tiles above the shower were falling down. One tile had brown discoloration over 75% of the tile around the ceiling fan. On 7/03/24 at 8:51 AM an interview and observation was conducted with the Maintenance Director (Staff #10) of the ceiling tile above the shower in room [ROOM NUMBER] on the Renaissance 1 Unit (MSU). Staff #10 looked at the ceiling tiles and stated that it might have been a water leak from the shower above (2nd floor). He stated that he will repair the ceiling tiles and will check the room/shower on the floor directly above to ensure there was no leak now. He was informed that this was found on the initial…

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 record review and interview with the facility staff, it was determined that the facility failed to provide a baseline care plan to the resident or the resident representative. This was evident for one (Resident # 6) out of 6 residents reviewed for dental services during the annual survey, and one (Resident #186) out of 3 closed records reviewed during the recertification survey. The findings include: The baseline care plan is given to residents within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive. 1) On 6/26/24 at 10:10 AM a record review of Resident #6's baseline care plans dated 8/21/23, 12/11/23 and 6/19/24 revealed that there was no documentation that the information was provided to the resident or 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.

Based on record review, observation, and interview, it was determined that the facility failed to update/revise care plans after an episode of fall and elopement attempt. This was evident for 1 (Resident #154) of 5 residents reviewed for care plans, and 1 (Resident #89) out of 2 residents reviewed for elopement during the annual and complaint survey. The findings include: 1) On 6/26/24 at 8:03 AM, a review of Resident #154's admission/discharge record revealed that the resident was initially admitted to the facility in December 2023. The resident was transferred to the hospital on 3/21/24 due to a fall incident. The resident was readmitted back to the facility on 4/02/24. On 6/24/24 at 8:21 AM, Resident #154 was observed inside his/her room sitting in a geriatric chair. The resident appeared anxious and kept getting up. The second observation on 6/24/24 at 9:47 AM noted that Resident #154 was sitting in the geriatric chair in the nurse's station. He/she tried to get out of the chair multiple times and was repositioned by the nurse. On 6/24/24 at 11:11 AM, during an interview 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.

Based on observation, interview, and medical record review it was determined the facility failed to: ensure a medical order was followed, ensure a medical order was present for a care intervention, and ensure a resident's call device was within reach. This was evident for 1 (resident #393) out of 7 residents reviewed for pressure injuries during the facility's recertification survey. The findings include: On 6/21/24 at 9:47AM the surveyor observed intact gauze wrapped dressings on each of Resident #393's feet with both feet resting directly on the surface of the bed. During an interview with Resident #393 on 6/21/24 at 9:55AM they reported to the surveyor that their call bell was not in reach and they needed assistance with repositioning. At this time, the surveyor observed a wedge pillow situated between the resident's right side of their body and the bed rail on their right side, with the call bell dangling onto the floor out of reach of the resident. At this time, the surveyor reported the concern to Licensed Practical Nurse (LPN) #51 who offered the following response: I have to…

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 medical record review and interview, the facility failed to provide adequate pressure ulcer management for a resident (resident #553). This was evident in 1 of 14 residents reviewed when investigating facility reported incidents and complaints during the facility's recertification survey. The findings include: Review of resident #553's medical record on 7/9/24 at 11:45am revealed the resident was admitted to the facility with a stage two sacral pressure wound. Continued review of the resident's medical record revealed that the resident's sacral pressure wound continued to worsen until the resident was assessed with a stage 4 sacral pressure wound approximately eight weeks later. Further review of the resident's medical record revealed that the facility failed to provide adequate pressure wound management treatments to attempt to prevent the worsening of the resident's sacral wound for approximately 8 weeks. The resident's attending provider ordered specialized wound care treatment after the resident was assessed with a stage 4 sacral pressure wound. Interview with 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.

Based on observation, medical record review, and interview it was determined the facility failed to 1) follow physician's orders and the resident's care plan for the administration of oxygen, 2) follow medical orders for respiratory care of a resident and ensure labeling and changing of respiratory equipment, and 3) ensure a medical order was present for respiratory care delivered, ensure a medical order was followed, and ensure labeling and changing of respiratory equipment. This was evident for 3 (Residents #49, #81, and #163) out of 4 residents reviewed for respiratory care during the recertification/complaint survey. The findings include. 1) Resident #49 was observed in bed on 6/21/24 at 8:44 AM receiving oxygen via nasal cannula (a tube worn in the nostrils to administer oxygen) that was attached to a water bottle connected to an oxygen concentrator (a machine that concentrates oxygen from room air). The flow meter scale with a metal ball was observed between the 4 line to show an oxygen flow rate of 4.0 liters per minute (LPM). Review of resident #49's medical record at 12:58…

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 record review and staff interview, a facility agency provider failed to place visit notes into a resident's medical record (resident #545) timely. This was evident for 1 of 14 residents reviewed when investigating facility reported incidents and complaints during the recertification survey. The findings includes: During the investigation of MD00181057, a review of resident #545's medical record on 7/8/24 at 9:29am revealed that the pharmacist consultant recommended a gradual dose reduction (GDR) for Seroquel (Quetiapine Fumarate). Continued review of resident #545's medical record revealed the facility contracted an agency psychiatric nurse practitioner (agency psychiatric NP) to assess the resident to ensure that the gradual dose reduction was safe for the resident. On 7/21/22, the agency psychiatric NP failed to assess the resident for a GDR due to his/her failure to locate Seroquel in the resident's medical orders. Further review of resident #545's medical record revealed the agency psychiatric NP put his/her visit notes into the resident's chart on 7/28/22. During a…

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 observation, interview and record review it was determined the facility failed to ensure residents remained free from unnecessary medications. This was evident for 2 (#138, #163) out of 9 residents reviewed for unneccessary medications during the facility's recertification survey, and 1 (resident #545) out of 14 reviewed during facility reported incident and complaint investigations during the recertification survey. The findings include: 1.) On 7/2/24 at 11:47AM the surveyor observed Resident #138 with the upper half of their body laying down horizontally across the shorter width of their bed and they verbally acknowledged the nurse's presence, however, their body position remained the same. Review of the medical record on 7/2/24 at 12:38PM by the surveyor revealed multiple mental health diagnoses documented for Resident #138. On 7/2/24 at 12:54PM the surveyor observed the following active medical orders for the resident: Seroquel Tablet 25 MG (Quetiapine Fumarate): Give 1 tablet by mouth two times a day for delusional disorder and Sertraline HCl Oral Tablet 50 MG…

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 observation and interviews it was determined that the facility failed to ensure 1) medications were securely stored, 2) all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and 3) failed to monitor and document daily, on the temperature log, the refrigerator temperature where residents' medications are stored to preserve their integrity. This was evident for 3 medication carts and on inspection of the medication rooms during the recertification survey. The findings include: 1) On 6/21/24 at 10:35AM the surveyor observed an unattended medication cart with the lock mechanism protruding outward on the 2 South Nursing Unit. Upon approaching the cart, the surveyor was able to open all drawers by use of the sliding mechanism and all medications stocked within the cart were observed to be accessible. On 6/21/24 at 10:37AM the surveyor conducted an interview of Licensed Practical Nurse (LPN) #58 upon their exit from a resident room, at which time the surveyor shared their concern. LPN #58 acknowledged…

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 interview and medical record review, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner, and 2) to assist a resident in scheduling a dental visit/appointment to obtain dental care outside the facility. This was evident for 2 (#49, #453) of 7 residents reviewed for dental services during a recertification/complaint survey. The findings include: 1) On 6/21/2024 during the initial pool screening, Resident #49 told a surveyor that s/he was seen by a dentist and indicated that s/he needed a new tooth but was told they were not sure if the resident's insurance will take care of it. On 6/27/2024 at 1:27 PM, a review of physician orders did not reveal any active orders for dental consult. However, further review revealed an order for dental consult dated 4/11/2023 that was discontinued on 2/3/2024: Dental Consult for loose tooth. No directions specified for order. Other…

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 observation, medical record review, and interviews, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (Resident #131, #105) of 77 residents reviewed during a recertification /complaint survey. The findings include: Hemodialysis or simply dialysis is a process of filtering the blood of a person whose kidneys are not working normally. A hemodialysis (dialysis) catheter is used to access your blood for hemodialysis. It is a soft tube placed in a large vein in the neck, chest or groin. An arteriovenous (AV) fistula is a connection that's made between an artery and a vein for dialysis access. A surgical procedure, done in the operating room, is required to stitch together two vessels to create an AV fistula. 1) During a review of Resident #131's medical record conducted on 7/2/2024 at 10:27 AM, surveyor noted active physician orders for two different dialysis access: - ARM FISTULA: Left upper arm. MONITOR FOR BRUIT AND THRILL EVERY SHIFT every shift for MONITORING…

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 observation, interview, and medical record review it was determined the facility failed to: 1) ensure staff donned appropriate personal protective equipment for enhanced barrier precautions, and ensure the medical order for enhanced barrier precautions was timely implemented and followed, and 2) use appropriate infection control practice during urinary catheter maintenance. This was evident for 1 (Resident #393) out of 7 residents reviewed for pressure injuries and 1 (Resident #6) out of 4 residents reviewed for urinary catheter during the recertification survey. The findings include: During an interview with Resident #393 on 6/21/24 at 9:55AM they reported to the surveyor that their call bell was not in reach and they needed assistance with repositioning. At this time, the surveyor reported the concern to Licensed Practical Nurse (LPN) #51 who offered the following response: I have to go find their nurse because of the sign on the door, it's not my patient. At this time, the surveyor further noted the signage on the door to the room which indicated that enhanced barrier…

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 record review and staff interview, it was determined that the facility staff failed to document that residents and/or their Responsible Parties (RPs) were provided education on the Influenza vaccine before requesting consent. This was evident for 1 (Resident #109) of 5 residents reviewed for Immunizations during the survey. The findings include: Flu is a contagious disease that spreads around the United States every year, usually between October and May. Anyone can get the flu, but it is more dangerous for some people. Infants and young children, people 65 years and older, pregnant people, and people with certain health conditions or a weakened immune system are at the greatest risk of flu complications. Influenza (Flu) vaccines can prevent influenza. (Centers for Disease Control and Prevention- vaccines and preventable disease) During an interview with the Infection Control Preventionist (Staff #15) on 07/02/24 at 9:09 AM, Staff #15 stated, I go over Flu and Pneumonia vaccine, get consents. I give the residents or family members flyers for education if they refuse. All…

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 record review and interviews with staff, it was determined that the facility failed to ensure that the allegations of injury of unknown, and alleged abuse were reported to the state agency within the required timeframe. This was evident for two (Resident #75 and #89) of seven residents reviewed for injury of unknown origin during the facility's recertification survey. The findings include: 1) On 6/25/24 at 8:31 AM, the surveyors investigated Facility Self-Reported incident MD00201951. The incident was about Resident #75, who had left arm swelling noted on 1/25/24 at 9 PM, and an X-ray revealed an acute fracture of the proximal/mid humerus. Further review of Resident #75's medical records on 6/25/24 at 8:59 AM revealed that an assigned nurse of Resident #75 initially observed bluish discoloration on the lower and upper left arm accompanied by pain and swelling on 1/25/24 at 8:50 PM. The physician was notified and ordered an X-ray of the left arm at 9:20 PM on 1/25/24. Resident #75's electronic medical record showed that the X-ray was taken on 1/26/2024 at 3:29 PM, and 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.

Based on a review of the facility investigations, interviews, and record reviews, it was determined that the facility failed to thoroughly investigate an injury of unknown origin and an elopement incident. This was evident for 2 (Resident #75 and Resident #109) of 19 residents reviewed for Facility Reported Incidents during a recertification survey. The findings include: Wanderguard is a wandering management system. The system used a wearable bracelet to monitor residents. A WanderGuard system relies on three components: bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time . When a resident with a bracelet approaches a monitored door, the system alerts. 1) On 6/25/24 at 8:31 AM, the surveyors investigated Facility Self-Reported incident MD00201951, an injury of unknown origin. The review revealed that on 1/25/24 at 8:50PM, Resident #75 was initially observed with bluish discoloration on the lower and upper left arm accompanied by pain and swelling. The physician was notified and ordered an Xray to the left arm at…

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 a review of the facility investigation, record review, observation, and interview, it was determined that the facility failed to identify and provide appropriate treatment and services to assist residents in attaining their highest practicable mental health. This was evident for 1 (Resident #109) of 5 residents reviewed for behavior-emotional well-being during the annual survey. The findings include: Wanderguard is a wandering management system that monitors residents using a wearable bracelet. The system relies on three components: bracelets that residents wear, sensors that monitor doors, and a technology platform that sends real-time safety alerts. When a resident with a bracelet approaches a monitored door, the system alerts. On 6/26/24 at 12:50 PM, surveyors investigated Facility Self-Reported incident MD00203918. Resident #109 had an elopement incident on 3/22/24 around 9:30 AM. The self-report form indicated that Resident #109 cut off his/her wander guard and eloped from the facility building through the main entrance door, following another visitor. At 10:30 AM, 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.

Based on observation, interview with residents' families, and review of medical record, it was determined that the facility failed to ensure that residents with limited mobility received appropriate equipment to maintain mobility and independence. This was evident for 1 (Resident #129) of 2 residents reviewed for position and mobility. The findings include: Resident #129's medical record was reviewed on 10/4/19 at 8:21 AM. During the review, orders were found that stated, resident is dependent for mobility, and Out of Bed to Wheelchair. It was also found that the resident was not able to make his/her own decisions. The most recent Minimum Data Set Assessment for the resident was coded that the resident requires assistance with locomotion while in a wheelchair. During an interview with Resident #129's responsible party (RP) that took place on 10/3/19 at 3:08 PM, the resident's RP stated that s/he had been told by the facility's physical therapy department that the resident required footrests on the wheelchair to assist in maintianing his/her upright position; otherwise the resident…

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 review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that residents' as-needed pain medication orders specified the parameters when they should be given. This was evident for 1 (Resident #3) of 6 residents reviewed for unnecessary medication. The findings include: Resident #3's medical record was reviewed on 10/2/19 at 11:10 AM. During the review, it was determined that the resident had a condition that caused chronic pain. Active orders for two as-needed pain medications were identified, one for acetaminophen (Tylenol) and the other for oxycodone. The acetaminophen order stated, give 650mg every 6 hours as needed for mild pain. The oxycodone order stated, give 5mg every 6 hours as needed for pain. The oxycodone order did not specify what pain severity it should be administerd for, and neither order specified numeric parameters using the numeric pain scale. Oxycodone is a narcotic pain reliever that, although stronger than acetaminophen, causes more significant side effects and is sedating. Excessive…

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 observation and interview with facility staff, it was determined that the facility failed to ensure that dishes and utensils were cleaned in a sanitary manner as evidenced by the high temperature dishwasher not reaching the expected final rinse temperature. This was evident for 1 of 2 observations of the kitchen. The findings include: During an observation of the kitchen made on 9/26/19 at 9:23 AM and in the presence of the Food Service Director (FSD), the main dishwasher was noted to reach a final rinse temperature of 163 degrees Fahrenheit (F). The FSD stated that the dishwasher was a high temperature, chemical-free dishwasher and that the final rinse temperature should be 180 degrees F. The FSD directed his staff to begin sanitizing items which a chlorine-based sanitizer for at least 30 seconds prior to sending them into the dishwasher. The FSD stated that he would contact the representative from the company that maintains the dishwasher and involve the Director of Maintenance in evaluating the flash heater that supplied the dishwasher. During a follow up visit that took…

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.