Lorien Mays Chapel

Survey Date: Thursday, July 10, 2014
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: D
Deficiency Corrected: Past Non-Compliance
Date the deficiency was corrected: Thursday, July 10, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)

Survey Date: Thursday, July 10, 2014
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, August 23, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)

Survey Date: Thursday, July 10, 2014
Survey Type: Health
Deficiency: F0328 (Properly care for residents needing special services, including: injections, colostomy, ureostomy, i)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, August 23, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a complaint inspection)

Survey Date: Friday, January 17, 2014
Survey Type: Health
Deficiency: F0272 (Conduct initial and periodic assessments of each resident's functional capacity.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Friday, January 17, 2014
Survey Type: Health
Deficiency: F0279 (Develop a complete care plan that meets all the resident's needs, with timetables and actions that c)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Friday, January 17, 2014
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Friday, January 17, 2014
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Friday, January 17, 2014
Survey Type: Health
Deficiency: F0431 (Maintain drug records and properly mark/label drugs and other similar products according to accepted)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Friday, January 17, 2014
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Friday, January 17, 2014
Survey Type: Health
Deficiency: F0280 (Allow residents the right to participate in the planning or revision of care and treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Friday, January 17, 2014
Survey Type: Health
Deficiency: F0241 (Provide care for residents in a way that maintains or improves their dignity and respect in full rec)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Friday, January 17, 2014
Survey Type: Health
Deficiency: F0428 (At least once a month, have a licensed pharmacist review each resident's medication (s) and report a)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, February 6, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 2, 2014
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, February 7, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 2, 2014
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, February 7, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 2, 2014
Survey Type: Fire Safety
Deficiency: K0072 (Exits that are free from obstructions and can be used at all times.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, February 7, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 2, 2014
Survey Type: Fire Safety
Deficiency: K0052 (An approved installation, maintenance and testing program for fire alarm systems.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, February 7, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 2, 2014
Survey Type: Fire Safety
Deficiency: K0056 (An approved automatic sprinkler system connected to the fire alarm system.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, February 7, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 2, 2014
Survey Type: Fire Safety
Deficiency: K0070 (Restrictions on the use of portable space heaters.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, February 7, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, January 2, 2014
Survey Type: Fire Safety
Deficiency: K0069 (Properly protected cooking facilities.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, February 7, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, June 4, 2013
Survey Type: Health
Deficiency: F0157 (Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decl)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, June 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)

Survey Date: Tuesday, June 4, 2013
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, June 21, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)

Survey Date: Tuesday, November 20, 2012
Survey Type: Health
Deficiency: F0225 (1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) rep)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 21, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, November 20, 2012
Survey Type: Health
Deficiency: F0279 (Develop a complete care plan that meets all the resident's needs, with timetables and actions that c)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 21, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, November 20, 2012
Survey Type: Health
Deficiency: F0280 (Allow residents the right to participate in the planning or revision of care and treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 21, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, November 20, 2012
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 21, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, November 20, 2012
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 21, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, November 20, 2012
Survey Type: Health
Deficiency: F0156 (Give residents a notice of rights, rules, services and charges.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 21, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, November 20, 2012
Survey Type: Health
Deficiency: F0431 (Maintain drug records and properly mark/label drugs and other similar products according to accepted)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 21, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, November 20, 2012
Survey Type: Health
Deficiency: F0520 (Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, a)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, December 21, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, November 6, 2012
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 9, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, November 6, 2012
Survey Type: Fire Safety
Deficiency: K0021 (Exit doors that are held open by devices that will automatically close on the activation of a fire a)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 9, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, November 6, 2012
Survey Type: Fire Safety
Deficiency: K0038 (Exits that are accessible at all times.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 9, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, November 6, 2012
Survey Type: Fire Safety
Deficiency: K0066 (Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, November 9, 2012
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Monday, July 30, 2012
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, August 13, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Tuesday, July 3, 2012
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 26, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Tuesday, July 3, 2012
Survey Type: Health
Deficiency: F0253 (Provide housekeeping and maintenance services.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 26, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Tuesday, July 3, 2012
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 26, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Friday, December 9, 2011
Survey Type: Health
Deficiency: F0159 (Properly hold, secure, and manage each resident's personal money which is deposited with the nursing)
Scope Severity Code: B
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, January 6, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Friday, August 26, 2011
Survey Type: Health
Deficiency: F0253 (Provide housekeeping and maintenance services.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, November 1, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, August 26, 2011
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, November 1, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, August 26, 2011
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, November 1, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 8, 2011
Survey Type: Fire Safety
Deficiency: K0130 (Other fire safety features required by fire safety codes.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, August 1, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 8, 2011
Survey Type: Fire Safety
Deficiency: K0025 (Walls that prevent smoke from passing through and would resist fire for at least one hour.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, August 1, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 8, 2011
Survey Type: Fire Safety
Deficiency: K0067 (Heating and ventilation systems that have been properly installed according to the manufacturer's in)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, August 1, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 8, 2011
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: B
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, August 1, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 8, 2011
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, August 1, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 8, 2011
Survey Type: Fire Safety
Deficiency: K0072 (Exits that are free from obstructions and can be used at all times.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, August 1, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, June 8, 2011
Survey Type: Fire Safety
Deficiency: K0064 (Portable fire extinguishers.)
Scope Severity Code: B
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, August 1, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)