Lorien Mays Chapel

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that oxygen tubing was changed and dated as per the physician orders and according to the oxygen therapy facility policy and procedures. This was evident in 4 (#56, #46, #38, #5) of 5 residents observed receiving oxygen during the annual survey.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that required beneficiary protection notifications were provided to a resident. Specifically, the facility did not issue the Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN), Form CMS-10055, as applicable. This deficient practice was identified for 1 of 3 residents reviewed for Beneficiary Protection Notifications (Resident #38).

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that residents' environment was clean and well maintained. This was found to be evident for 1 (Resident # 101) of 40 residents observed on the third floor during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure that a gradual dose reduction (GDR) was attempted for an antianxiety medication and failed to provide adequate clinical documentation supporting the continued use of the medication. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #8).

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to provide written information to the resident and/or the resident responsible party (RP) regarding a hospital transfer and provide them with a copy of the facility's bed hold policy. This was found to be evident for 1 (Resident # 90) of 3 residents reviewed for hospitalizations during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on observations, staff interviews, and record review, it was determined that the facility failed to develop and implement a complete, comprehensive care plan. This was evident for 1 (Resident #38) out of 6 residents reviewed during this annual survey. A comprehensive person-centered care plan for each resident must include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Inspectors wroteBased on observations, staff interviews, and record review, it was determined that the facility failed to ensure that the comprehensive care plan was reviewed and revised after each assessment. It was evident for 1 (Resident #38) out of 6 residents reviewed during this annual survey.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician orders. This was evident 1 (Resident #46) out of 1 residents observed receiving oxygen during the annual survey.

Inspectors wroteBased on observations, administrative record review, and interviews, the facility failed to ensure the staffing ratios and assigned the registered nurse for the unit was posted on the white board utilized to display the staffing assignments on the clinical unit. This was evident to be true for 1 out of 2 clinical units observed during an annual survey.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accuracy and timeliness of controlled substance documentation, resulting in unresolved discrepancies in narcotic counts. This was evident in 2 of 2 medication count reconciliations observed and reviewed for accuracy during the recertification survey.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure medications were securely stored and controlled to prevent unauthorized access, and failed to ensure timely storage of medications upon delivery in accordance with accepted professional standards of practice. This deficient practice was identified in 1 (Resident #20) of 1 resident observed for medication storage during the annual recertification survey.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that dishes were cleaned and stored properly, dishwashing machine temperatures were consistently entered on the dishwasher log, and, foods were dated upon opening and stored in a sanitary environment. This was found to be evident during the initial tour of the kitchen during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form. This was evident for 1 (#46) out of 6 residents' medical records reviewed during the annual survey.

Inspectors wroteBased on observation and staff interviews it was determined that the facility failed to maintain a safe and effective system for securing medication located in their designated treatment carts on nursing units. This practice was observed on both units of the facility involving 3 of 4 of the posted treatment carts.

Inspectors wroteBased on observation, record review and interviews, it was determined that the facility failed to maintain residents' medical records in a secure location. This was evident for the 4 (Resident #s 8, 25, 53, and 56) of 4 residents' charts observed during the recertification/complaint survey on the 2nd floor nursing unit.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the abuse, neglect, exploitation and misappropriation policy was developed to include the required necessary reporting and response timeframes. This was evident during the surveyor's review of 1 out of 1 policy the facility had in place to prohibit and prevent abuse, neglect, expolitation and misappropriation during the facility's recertification/complaint survey.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure that stored food items were labeled and were not expired. This was evident during the initial tour of the food service department during the recertification/complaint survey.

Inspectors wroteBased on a facility reported incident MD00204294, observation, record review, and staff interviews, it was determined that the facility failed to protect a resident's right to be free from any type of abuse. This was evident for 1(#28) of 15 residents reviewed for abuse during the facility's recertification/complaint survey.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a thorough review of background check results during the hiring process for a geriatric nursing assistant who had been employed with the facility for approximately one year. This was evident for 1 (GNA #16) out of 1 previously employed geriatric nursing assistant which was reviewed during investigation of an allegation of abuse for facility reported incident #MD00206160 during the facility's recertification/complaint survey.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure: 1) timely reporting of a serious injury of unknown source (Residents #9, #82, #6 ), and 2) timely reporting of an allegation of abuse (Resident #81). This was evident for 4 (MD#00194057, MD#002044306, MD#00212835, #MD00181864) of 20 facility reported incidents reviewed during the facility's recertification/complaint survey. Findings Include: Situation, Background, Assessment, and Recommendation (SBAR) is a communication tool that helps healthcare professionals to share information about a patient's condition in a concise manner. [...]

Inspectors wroteBased on interview and record review it was determined the facility failed to: 1) ensure measures were taken to protect a resident (Resident #81) during an investigation of an allegation of abuse and 2) thoroughly investigate an allegation of abuse. This was evident for 1 (#MD00181864) out of 20 facility reported incidents reviewed during the facility's recertification/complaint survey.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing. This was evident for 1 (#55) of 2 residents reviewed for hospitalization during the recertification/complaint survey. Findings Include: On 1/21/25 at 8:41AM review of Resident #55's medical records revealed that s/he was hospitalization on 3 different dates in 2024 which were 1/16/24, 8/25/24 and 10/12/24. Further review did not show that the resident or their representatives were given a written notification of the transfer. In an interview with the Director of Nursing on 1/21/25 at 11:47 AM, she was asked about the notification process. [...]

Inspectors wroteBased on review of medical records and interview with facility staff, it was determined that the facility failed to provide a baseline care plan summary to residents. This was evident for 1 (#79) of 7 residents reviewed for baseline care plans during the recertification/complaint survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure the care plan was reviewed and updated by the interdisciplinary team after the care plan meeting. This was evident for 1 (Resident #7) of 2 residents reviewed for the use of a feeding tube during the recertification/complaint survey. Findings Include: A gastrostomy tube (G-tube) is a tube that is surgically inserted through the abdomen and brings nutrition directly to the stomach. The Minimum Data Set (MDS) is a standardized comprehensive assessment tool that measures health status in nursing home residents. On 01/09/25 09:20 AM, record review revealed that Resident #7 had 4 separate incidents of G-tube dislodgement between the months of July 2024 and October 2024. On 2 of 4 G-tube dislodgment, the resident was transferred to the emergency room for further evaluation. [...]

Inspectors wroteBased on a facility report MD00205422, record review, and staff interviews, it was determined that the facility failed to provide and utilize an assistive device to transfer a resident as ordered. This was evident for 1(Resident #281) of 20 facility reported incidents reviewed during the recertification/complaint survey.

Inspectors wroteBased on record review and interview it was determined the facility failed to ensure the monitoring of a medication for a resident. This was evident for 1 (Resident #4) out of 5 residents reviewed for unnecessary medications during the recertification/complaint survey.

Inspectors wroteBased on record review and interview it was determined the facility failed to ensure the monitoring of a psychotropic medication. This was evident for 1 (Resident #4) out of 5 residents reviewed for unnecessary medications during the facility's recertification/complaint survey.

Inspectors wroteBased on a complaint incident #MD00191927, record review and interviews, it was determined that the facility failed to ensure that a resident was free from significant medication errors. This was evident for 1 (Resident #86) of 10 complaints reviewed during the facility's recertification/complaint survey.

Inspectors wroteBased on a facility reported incident, complaint, observation, record review and interview it was determined the facility failed to: 1) secure residents medication properly, evidenced by leaving medications unsupervised at the bedside, resulting in a foreign object accidental ingestion. 2) ensure a medication cart was locked while unattended. This was evident for: 1) 1 (Resident #282) of 30 intakes reviewed, and 2) 1 out of 4 medication carts located on the second floor of the facility, during the facility's recertification/complaint survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that the resident medical records provided during the survey process contained sufficient information to identify the care provided to each resident. This was true for 2 (Resident #7 and Resident #82) of 18 resident medical records reviewed in the survey sample during the recertification/complaint survey. Findings Include: A gastrostomy tube (G-tube) is a tube that is surgically inserted through the abdomen and brings nutrition directly to the stomach. Situation, Background, Assessment, and Recommendation (SBAR) is a communication tool that helps healthcare professionals to share information about a patient's condition in a concise manner. [...]

Inspectors wroteBased on observation, interview and medical record review it was determined the facility failed to: 1) ensure the accuracy of infection control signage, and 2) ensure all employees' required immunizations were up to date, as it relates to infection prevention and control. This was evident for: 1) 5 of 83 resident occupied rooms at the time of the surveyor's initial tour, and 2) 3 (GNA #22, GNA#23, GNA#24) of 5 employees reviewed, during the facility's recertification/complaint survey.

Inspectors wroteBased on review of resident records and facility policy and interview with facility staff, it was determined that the facility failed to ensure that each resident was offered a pneumococcal vaccine. This was evident for 1 (Resident #19) of 5 residents sampled for review of influenza and pneumococcal vaccination.

Inspectors wroteBased on record review, staff interview, and policy review, it was determined that the facility failed to provide education to residents regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine and the opportunity to accept or refuse a COVID-19 vaccine. This was evident for 1 (Resident #13) of 5 residents sampled for review of COVID-19 immunizations during the recertification/complaint.

Inspectors wroteBased on interview with members of the Resident Council and a tour of the facility it was determined that the facility staff failed to ensure signage was posted to inform the residents of the location of the state survey results. This was evident for 2 out of 2 resident units.

Inspectors wroteBased on medical record review and staff interview it was determined that the facility staff failed to evaluate and update a resident's plan of care after each assessment. This was evident for 1 (#16) of 6 residents reviewed for unnecessary medications and 1 (#28) of 1 residents reviewed for activities.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure staffing information was posted as required. This was evident for 2 out 2 nursing units. This surveyor toured both nursing units on 2/21/20 at 12:17 PM. Other surveyors toured on 2/21/20 but at different times. The team did not observe postings for either floor. The Director of Nursing was interviewed on 2/21/20 at 2:00 PM.

Inspectors wroteBased on resident interviews, surveyor observation and staff interview, it was determined that the facility failed to serve food at a preferable/palatable temperature. This was evident for 3 (#54, #87, #83) of 22 initial pool residents and 4 of 4 food items tested for temperature.

Inspectors wroteBased on surveyor observation and staff interview, it was determined that the facility staff failed to properly label, and date food items stored in the main kitchen. This was evident during the initial tour of the kitchen.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to notify the physician when Resident (#75) had refused medication for 7 days. This was evident for 1 of 45 residents selected for review during the survey process.

Inspectors wroteBased on surveyor observation it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable and homelike environment. This was evident for 1 of 13 resident bathrooms observed on the 2nd floor.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to notify the resident and/or responsible party in writing of a Resident's (#43, #81) transfer to the hospital and the reason for transfer. This was evident for 2 of 2 residents reviewed for hospitalizations.

Inspectors wroteBased on medical record review and staff interview it was determined the facility 1) failed to develop and implement comprehensive, person-centered care plans with non-pharmacological approaches to care for a resident receiving psychotropic medication, and, 2) failed to follow a resident's care plan related to administering oxygen. This was evident for 1 (#16) of 6 residents reviewed for unnecessary medications and 1 (#28) of 1 resident reviewed for respiratory care.

Inspectors wroteBased on observation, medical record review, and staff interview, it was determined the facility failed to implement an ongoing resident centered activities program to meet the interests and support the physical, mental and psychosocial well-being of each resident. This was evident for 1 (#28) of 1 resident reviewed for activities.

Inspectors wroteBased on medical record review and interviews with facility staff, it was determined that the facility staff failed to follow a written physician order (Resident #81). This is evident for 1 of 2 resident's reviewed for discharge to the community during the annual survey.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility failed to maintain the environment for Resident (#19) free from potential accidents. This was evident for 1 of 1 resident selected for review of accidents and 1 of 45 residents selected for review during the annual survey process.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined the facility staff failed to ensure oxygen was administered at the rate ordered by the physician, failed to accurately document the resident's oxygen rate in the treatment record, failed to ensure the resident's oxygen tubing was changed per the physician's order, failed to ensure a physician's order addressed the resident's use of oxygen humidification and failed to follow the resident's oxygen therapy care plan. This was evident for 1 (#28) of 1 resident reviewed for respiratory care.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to ensure physician medical visit notes were in residents' medical records on the day the residents were seen. This was evident for 2 (#28, #63) of 5 residents reviewed for position, mobility.

Inspectors wroteBased on review of employee files and staff interview, it was determined that the facility failed to have evidence of skills competencies for 2 geriatric nursing assistants (GNA #3, #4). This was identified for 2 of 4 GNA's reviewed during the annual survey.

Inspectors wroteBased on review of employee files and staff interview, it was determined that the facility failed to have a Geriatric Nursing Assistant (GNA #3) complete the annual required 12 hours of education based on the annual performance review. This was identified for 1 of 4 GNA staff members reviewed during an annual recertification survey.

Inspectors wroteBased on record review, observation and interview it was determined the facility staff failed ensure Resident (#48) was free from unnecessary medication. This was evident for 1 opportunity out of 28 for error and 1 out of 4 residents observed for medication pass.

Inspectors wroteBased on medical record review and staff interview it was determined that the facility staff administered anti-psychotic medication without adequate indication of need. This was evident for 1 (#16) of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on record review, observation and interview it was determined the facility staff failed to obtain a medication error rate less than 5%. This was evident for 2 errors out of 28 opportunities and 1 out of 4 residents observed for medication pass (Resident #48) resulting in an error rate of 7.14%.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to obtain laboratory blood specimen on Resident (#5) as ordered by the physician. This 1 of 45 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to maintain the medical record for Resident (#19) in the most accurate and complete form. This was evident for 1 of 45 residents selected for review during the annual survey.

Inspectors wroteBased on observation of medication pass it was determined the facility staff failed to administer medications in a manner which promoted the most infection control for Resident (#48) and failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to label and store resident care equipment in a manner to prevent development and transmission of disease and infection. This was evident for 1 of 4 residents observed for medication pass with 1 out of 28 opportunities for error and this was evident in 3 of 13 resident bathrooms observed on the 2nd floor during the survey.