A list of the most recent deficiencies for Lorien Health Systems Mt Airy. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-28 | 2023-02-28 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-12-28 | 2023-02-28 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-12-28 | 2023-02-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-28 | 2023-02-28 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-12-28 | 2023-02-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-28 | 2023-02-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-12-28 | 2023-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-28 | 2023-02-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-28 | 2023-02-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-28 | 2023-02-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-28 | 2023-02-28 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-12-28 | 2023-02-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-12-28 | 2023-02-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-28 | 2023-02-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-28 | 2023-02-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-12-14 | 2023-01-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-14 | 2023-01-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-12-14 | 2023-01-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-12-14 | 2023-01-27 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-12-14 | 2023-01-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-14 | 2023-01-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-14 | 2023-01-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-14 | 2023-01-27 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-12-14 | 2023-01-25 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-12-14 | 2023-01-25 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-14 | 2023-01-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-14 | 2023-01-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-14 | 2023-01-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-14 | 2023-01-25 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-09 | 2021-10-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-09 | 2021-10-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-03 | 2019-07-19 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2019-06-03 | 2019-07-19 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-06-03 | 2019-07-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-03 | 2019-07-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-06-03 | 2019-07-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-03 | 2019-07-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-06-03 | 2019-07-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-03 | 2019-07-19 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-06-03 | 2019-07-19 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-06-03 | 2019-07-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-06-03 | 2019-07-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-06-03 | 2019-07-19 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-06-03 | 2019-07-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-06-03 | 2019-07-19 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-06-03 | 2019-07-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-03 | 2019-07-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-05-29 | 2019-06-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-29 | 2019-06-21 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-05-29 | 2019-06-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-29 | 2019-06-21 | N |
| Meet other general requirements. | Fire Safety | 2019-05-29 | 2019-06-17 | N |
| Have an externally vented heating system. | Fire Safety | 2019-05-29 | 2019-06-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2017-12-08 | 2018-01-26 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2017-12-08 | 2018-01-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-12-08 | 2018-01-26 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-12-08 | 2018-01-26 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2017-12-08 | 2018-01-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2017-12-08 | 2018-01-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-08 | 2018-01-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2017-12-08 | 2018-01-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2017-12-08 | 2018-01-26 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2017-12-08 | 2018-01-26 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2017-12-08 | 2018-01-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2017-12-08 | 2018-01-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2017-12-08 | 2018-01-26 | N |
| Provide or obtain dental services for each resident. | Health | 2017-12-08 | 2018-01-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2017-12-08 | 2018-01-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-12-11 | 2018-01-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-12-11 | 2018-01-05 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2017-12-11 | 2018-01-05 | N |
| Have an externally vented heating system. | Fire Safety | 2017-12-11 | 2018-01-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-12-11 | 2018-01-05 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2017-12-11 | 2018-01-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-12-11 | 2018-01-05 | N |
