Deficiency Records for Lorien Health Systems Mt Airy
Updated as of November 01, 2019
This is not the most recent data for Lorien Health Systems Mt Airy. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 ne | 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 schedul | 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 other general requirements that are deficient. | 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 |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-08-29 | 2018-10-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2017-12-08 | 2018-01-26 | Y |
| 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 ne | 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 |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-05-11 | 2017-05-18 | Y |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-05-11 | 2017-05-18 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-05-11 | 2017-05-18 | Y |
| Provide housekeeping and maintenance services. | Health | 2016-12-09 | 2017-03-03 | N |
| Keep all essential equipment working safely. | Health | 2016-12-09 | 2017-02-09 | N |
| Meet other general requirements. | Fire Safety | 2016-12-15 | 2017-02-03 | N |
| Have exits that are accessible at all times. | Fire Safety | 2016-12-15 | 2017-02-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2016-12-15 | 2017-02-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2016-12-15 | 2017-02-03 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2016-12-15 | 2017-02-03 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2016-12-15 | 2017-02-03 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-12-09 | 2017-01-31 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-12-09 | 2017-01-31 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-12-09 | 2017-01-31 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2016-12-09 | 2017-01-31 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-12-09 | 2017-01-31 | N |
| Give or get x-rays and other tests in a timely manner to meet the needs of residents. | Health | 2016-12-09 | 2017-01-31 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-12-09 | 2016-12-31 | N |
