Lorien Health Systems Mt Airy

In the surveyor’s words

From the most serious findings on record at Lorien Health Systems Mt Airy, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF730Jul 31, 2026

  Based on record reviews and interviews it was determined that facility failed to ensure employee annual performance evaluations were conducted. This was found to be evident for 5 Geriatric Nursing Assistants (GNA) (GNA #6, GNA #7, GNA #8, GNA #9 & GNA #10) out of 5 employee files reviewed during the recertification and complaint survey. The findings include:An employee performance evaluation is a structured, periodic process where an organization assesses an employee's job performance, skills, and work habits against pre-established expectations. […]

• No harm, potential for more than minimal, patternF641May 7, 2026

  Based 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.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.1) On 5/5/26 at 9:03 AM a review of Resident #9's medical record was conducted… […]

• No harm, potential for more than minimal, patternF584Dec 14, 2022

  Based 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. The findings include: On 12/14/22 at 9:13 AM an environmental tour was conducted with the Director of Maintenance, Staff #36. The following environmental and housekeeping observations were shown to Staff #36 and discussed: The ceiling tile outside of room [ROOM NUMBER] in the hallway had an approximate 6 inch brown circular stain. In room [ROOM NUMBER] the wall to the right of the door and under the window had areas of spackle over the paint. […]

• No harm, potential for more than minimal, patternF685Dec 14, 2022

  Based 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. The findings include: 1) A review of Resident #16's medical record on 12/07/22 revealed that Resident #16 was seen and assessed by the facility's eye physician on the following days and prescribed medications to treat the following conditions: a) on 07/19/22, Resident #16's eye physician documented that Resident #16 suffered from a history of Corneal neovascularization of the right eye, had Conjunctival hyperemia in both the right and left eyes that were getting worse, and that both eyes have long-standing tenderness that comes and… […]

• No harm, potential for more than minimal, patternF757Dec 14, 2022

  Based 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. The findings include: 1) On 12/13/22 at 10:09 AM a review was conducted of Resident #3's medical record. Review of physician's orders that were written on 7/13/22 revealed the order, Carvedilol 12.5 mg. […]