Health inspection·June 14, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, review of the local health department inspection reports, and facility policy review, the facility failed to ensure the kitchen was properly cleaned and sanitized prior to completing food preparation. The deficient practice had the potential to affect 127 residents who receive food from the kitchen. There was one resident (Resident #123) who was identified as having an ordered nothing by mouth (NPO) diet. Findings include: Review of the local health department (LHD) inspection report for the [NAME] Wing kitchen,completed on 06/10/24, evealed the kitchen was out of compliance with the following regulations: the person in charge demonstrated knowledge and performed duties; adequate handwashing facilities were supplied and accessible; food-contact surfaces were cleaned and sanitized; contamination was prevented during food preparation, storage, and display; non-food contact surfaces were clean; sewage and wastewater was properly disposed; and physical facilities were installed, maintained and cleaned. The inspection revealed four critical violations and three non-critical violations cited. The report stated there were gaps in practices and procedures identified through the inspection which could cause food-[NAME] illness. There was visual evidence of food debris in the handwashing sink. The inside chute of the ice machine was found to have mold present. The grease trap removal and pipes caused a back-up of wastewater and sewage into the kitchen. Food preparation continued in the kitchen during this time. There was standing water observed in the two adjourning storage rooms directly off of the kitchen. There was evidence of food preparation activity in the [NAME] Wing kitchen without the kitchen being cleaned and sanitized. There were accumulated boxes and dirt found in the dish area and the storage rooms needed to have all contents removed and discarded. The floors were dirty and there had been a milk spill in the walk-in cooler. Interview on 06/13/24 at 12:33 P.M. with Dietary Manager (DM) #200 confirmed the [NAME] Wing kitchen had been used for food preparation prior to the inspection by the LHD on 06/10/24. DM #200 confirmed the kitchen needed to have repairs completed before the kitchen could be used again. Interview on 06/13/24 at 3:18 P.M., via telephone, with [NAME] #201 confirmed she had been hired a food preparation cook approximately three weeks ago. [NAME] #201 confirmed she completed food preparation in the [NAME] Wing kitchen prior to the LHD inspection on 06/10/24. [NAME] #201 stated there was grease and stuff coming up through the drains in the kitchen. [NAME] #201 stated she had brought some dry goods for baking from the [NAME] Wing kitchen over to the [NAME] Wing kitchen. [NAME] #201 stated she was going back and forth between the two kitchens initially until they realized the (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 3 Event ID: 365344 Printed: 05/15/2026 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 365344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Luxe Rehabilitation and Care Center 957 Becks Knob Road Lancaster, OH 43130 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)