Lorien Mays Chapel

In the surveyor’s words

From the most serious findings on record at Lorien Mays Chapel, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Apr 9, 2026

  Based 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.The findings include: 1. On 04/06/2026 at 12:54 PM, Resident #56 was observed receiving O2 at 2L/min. However, the O2 tubing was not labeled. The humidifier bottle was labeled with the date of 04/01/2026. […]

• No harm, potential for more than minimal, patternF583Jan 21, 2025

  Based 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. Findings include: On 01/09/25 10:35 AM, an observation on the second floor revealed that residents' charts were located on top of a wide filing cabinet in the hallway. The surveyors noted that 4 charts with residents' name and physician orders were found unattended on top of the file cabinet with the physician's order pages flagged (sticking out of the chart) and visible. […]

• No harm, potential for more than minimal, patternF607Jan 21, 2025

  Based 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. The findings include: On 1/8/25 at 7:59AM the surveyor conducted an entrance conference with the facility's Administrator at which time the surveyor requested a copy of the facility's abuse prohibition policy and procedures. […]

• No harm, potential for more than minimal, patternF812Jan 21, 2025

  Based 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. Findings include: On [DATE] at 08:10 AM, an observation during the kitchen tour revealed that there were: a 3 lbs can of strawberry topping with a used by date of [DATE]; a 6 lbs can of navy bean with unknown expiration date; 2 undated open bags cinnamon swirl bread with raisin and 2 undated open bags of hamburger buns. […]

• No harm, potential for more than minimal, isolatedF582Apr 9, 2026

  Based 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).Findings include:On 04/06/2026, the facility received Beneficiary Protection Notification Review forms for three residents, including Resident #38.On 04/08/2026 at 2:15 PM, the Director of Nursing (DON) returned the forms. […]