Lorien Health Systems Mt Airy

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#9, #1, #4, #3) of 12 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to follow wound care provider's orders for a resident. This was evident for 1 (Resident #8) of 3 residents reviewed for wound care during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to provide documentation that Advance Directives (AD) was reviewed with and/or information/education regarding advance directives provided to residents and/or their responsible representatives (RP). This was evident for 2 (#4 and #11) of 37 residents reviewed during a recertification/complaint survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan. This is evident for 1 (Resident #11) of 24 resident care plans reviewed during the survey process. The findings Included:A voiding trial is the removal of a urinary catheter allowing the bladder to fill with urine naturally, and monitoring voiding to see if the bladder has returned to normal so that the urinary catheter can be removed permanently. On 08/04/2025 at 2:21 PM, in a resident representative interview, they expressed concern for the Resident #11's recurrent Urinary Tract Infection (UTI). On 08/11/2025 at 1:11 PM, in an interview with RN #10, she reported that Resident #11 had a history of recurrent UTI. The resident was admitted to the facility without a urinary catheter; [...]

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to revise the care plan by the interdisciplinary team after each assessment. This was true for 1 (Resident #21) of 3 resident records reviewed for hospitalization during the recertification/complaint survey.

Inspectors wroteBased on Observation, record reviews and staff interviews, it was determined that the facility failed to label and date humidifier bottles and oxygen tubing with change dates per physician's orders. This was evident for 2 (#33 and #47) of 4 residents reviewed for Respiratory care during the recertification/complaint survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to assess the effectiveness of pain medication consistent with professional standards of practice. This was evident for 1 (Resident #2) of 5 resident records reviewed for unnecessary medications during the recertification/complaint survey.

Inspectors wroteBased on observation and interview it was determined facility staff failed to remove expired supplies from a medication cart. This was evident for 1 of 3 medication carts reviewed for medication storage and labeling during a recertification survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (Resident #65) of 37 residents reviewed during a recertification / complaint survey.

Inspectors wroteBased on review of facility documentation and interview, it was determined the facility staff failed to have a social service director and a medical director participate monthly in the facility's Quality Assessment Performance Improvement (QAPI) committee meetings.

Inspectors wroteBased on a complaint, medical record review, and interview, it was determined the facility failed to ensure staff followed physician orders as evidenced by failure to ensure residents receive medications as ordered by the physician. This was evident for 1 (Resident #69) of 37 residents reviewed during a recertification/complaint survey.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to protect the residents' rights to be free from verbal abuse perpetrated by staff. This deficient practice affected 2 (Resident #3 and Resident #5) of 18 sampled residents.

Inspectors wroteBased on the review of a facility reported incident, record review, interview with staff and observations, it was determined that the facility failed to administer medications to residents according to facility policy and standard nursing practice for resident medication rights. This was evident for 1(Resident #8) of 3 residents reviewed related to medication administration.

Inspectors wroteBased on the review of a complaint, medical records, facility policy and procedures and interview with staff, it was determined that the facility failed to have processes in place to ensure for the daily care and potential complications of residents' percutaneous endoscopic gastrostomy tubes (PEG inserting a feeding tube directly into the stomach through the abdominal wall). This was evident during the review of 5 (Residents #4, #6, #16, #17, #18) of 6 residents with PEG tubes secondary to a complaint during a complaint survey.

Inspectors wroteBased on the review of a facility reported incident, record review, interview with staff and observations, it was determined that the facility failed to administer medications to residents without any significant medication errors. This was evident for 1(Resident #8) of 3 residents reviewed related to medication administration.

Inspectors wroteBased on surveyor observations and staff interviews it was determined the facility staff failed to provide housekeeping and maintenance services necessary to keep the nursing unit and resident rooms in clean and good repair. This was evident during environmental tours conducted on 2 of 2 nursing units during the annual survey.

Inspectors wroteBased on the medical record review and staff interview, it was determined that the facility failed to provide treatment/services to maintain vision. This was evident for 2 (#16, #29) of 3 residents selected for reviews of vision care during the annual survey.

Inspectors wroteBased 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 blood pressure parameters for administering Carvedilol and Midodrine, blood pressure medications, and physician ordered glucose parameters for Levemir, which is a long acting insulin that helps control blood sugar levels. This was evident for 2 (#3, #21) of 7 residents reviewed for unnecessary drugs during the annual survey.

Inspectors wroteBased on observation, interview, and documentation review, it was determined the facility failed to ensure that, 1) equipment was maintained in proper working condition, 2) sanitary practices were followed while preparing food, and 3) food temperatures were consistently monitored and documented. This was evident during 2 of 2 visits to the facility kitchen during the annual survey.

Inspectors wroteBased on the reviews of a medical record, observation, and interviews with staff, it was determined that the facility staff failed to maintain a medical record in the most accurate form. This was evident for 4 (#16, #48, #20, #21) of 34 residents reviewed for medical record accuracy during an annual recertification survey.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident was offered the opportunity to develop an advance directive for 2 (#22, #55) of 2 sampled residents for advance directives.

Inspectors wroteBased on observation and interview it was determined that facility staff failed to protect Resident #261's right to confidentiality of his/her medical record. This was evident during a random observation on 1 of 2 nursing units.

Inspectors wroteBased on the reviews of a medical record, observation, and interviews with staff, it was determined that the facility staff failed to revise the physician wound care orders. This was evident for 1 (#16) of 5 residents reviewed for pressure sores during an annual recertification survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility pharmacist failed to identify and report irregularities in the resident's drug regimen to the physician, facility's medical director and the director of nursing. This was evident for 1 (#3) of 7 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, staff interview, and documentation review, it was determined facility staff failed to keep medication carts locked when unattended. This was evident on 1 of 2 nursing units observed during the annual survey.

Inspectors wroteBased on observation and staff interviews it was determined that the facility failed to implement an effective infection control program and facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to follow infection control guidelines during the handling of linens. This was evident for random observations made during the tour of the Prospect unit.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility staff failed to develop and implement a comprehensive, resident-centered care plans to meet the distinct needs of residents with dementia. This was evident for 2 (#48 and #22) of 27 resident reviewed during this survey.

Inspectors wroteBased on observation and medical record review, it was determined that facility staff failed to treat residents with dignity and respect by failing to provide mealtime assistance to eat in timely manner to a resident who was dependent on staff . This was evident for 1 (#44) of 27 residents in the final sample.

Inspectors wroteBased on resident interview, medical record review, and staff interview, it was determined that the facility failed to have a process in place to provide prior notice of care plan meetings to the resident. This was evident for 1 (#49) of 27 residents reviewed for care plans during the survey.

Inspectors wroteBased on observation and staff interview, the facility failed to 1) ensure that resident records remained secure and confidential, and 2) provide privacy for a resident while they were receiving care. This was evident for 1 of 3 observations of medication administration and for 1 (#49) of 1 resident reviewed for privacy.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to document accurately the medication administered to a resident on the Minimum Data Set (MDS). This was evident for 1 (#32) of 27 residents reviewed during the survey. The MDS is a federally-mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need.

Inspectors wroteBased on review of the medical record and interview with staff, it was determined that the facility staff failed to develop a baseline care plan and failed to provide residents/representatives with a copy of their baseline care plan and medication list. This was evident for 1 (#49) of 27 residents reviewed for care plans.

Inspectors wroteBased on observation, medical record review, and staff interview, it was determined that facility staff failed to evaluate and update a resident's care plan to reflect current needs and preferences. This was evident for 1 (#22) of 27 residents reviewed for care plans.

Inspectors wroteBased on review of medical records and interview with facility staff, it was determined that the facility failed to ensure that residents remained free of accidents while being transferred by facility staff. This was evident for 1 (#1) of 3 residents reviewed for accidents.

Inspectors wroteBased on medical record review and staff interview, it was determined that what the physician documented in the resident's progress notes, did not accurately reflect what was in the resident's medical records. This was evident for 2 (#12, #32) of 27 residents reviewed in final sample.

Inspectors wroteBased on review of resident medical records, it was determined that the facility failed to develop a plan of care that addressed the needs of a resident with dementia. This was evident for 2 (#37 and #48) of 6 residents reviewed for dementia care.

Inspectors wroteBased on medical record review and staff interview, it was determine that the facility staff failed to follow through on a pharmacy recommendation. This was evident for 1 (#48) of 6 residents reviewed for unnecessary medications during the investigation phase of the survey.

Inspectors wroteBased on review of medical record and interview with facility staff, it was determined that the facility staff ordered and administered an excessive amount of Coumadin to Resident. This was evident for 1 (#12) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on review of the medical record and interview with facility staff, it was determined the facility failed to ensure that residents receiving psychoactive medication received behavioral and mood monitoring for the conditions that the psychoactive medications were prescribed for. This was evident for 1 (Resident #37) of 6 residents reviewed for unnecessary medication.

Inspectors wroteBased on observation, it was determined that the facility failed to have a medication error rate of greater than 5%. This was based on 2 errors occurring over 31 opportunities for error during 3 observations of medication administration.

Inspectors wroteBased on observation, interviews with facility staff and resident, it was determined the facility failed to ensure that there was not greater than 14 hours between the resident receiving his/her last meal for the evening and the next scheduled meal. This was found to be evident 1 (#32) of 27 residents reveiwed during the facility's annual Medicare/Medicaid survey observation rounds.

Inspectors wroteBased on observation, policy review, and staff interview, the facility 1) failed to ensure that medications were administered in a sanitary manner, and 2) failed to follow infection control practices by handing residents' food in a safe and sanitary manner. This was evident for 1 of 3 medication administration observations for 2 residents (#159, #23) and 3 (#44, #22, and #24) of 7 residents at a table chosen for dining observation. These practices had the potential to affect all residents at the facility.