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Deficiency Records for Lorien Mays Chapel
A list of the most recent deficiencies for Lorien Mays Chapel. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Lorien Mays Chapel. 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 residents' personal and medical records private and confidential. | Health | 2025-01-21 | 2025-02-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2025-01-21 | 2025-02-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2025-01-21 | 2025-02-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-01-21 | 2025-02-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2025-01-21 | 2025-02-20 | 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 | 2025-01-21 | 2025-02-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2025-01-21 | 2025-02-20 | 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 | 2025-01-21 | 2025-02-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-01-21 | 2025-02-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-01-21 | 2025-02-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-01-21 | 2025-02-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2025-01-21 | 2025-02-20 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2025-01-21 | 2025-02-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-01-21 | 2025-02-20 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2025-01-21 | 2025-02-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2025-01-21 | 2025-02-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-01-21 | 2025-02-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2025-01-21 | 2025-02-20 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2025-01-21 | 2025-02-20 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2025-01-22 | 2025-01-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-01-22 | 2025-01-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-01-22 | 2025-01-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2025-01-22 | 2025-01-30 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2020-02-24 | 2020-03-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-02-24 | 2020-03-27 | 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 | 2020-02-24 | 2020-03-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-24 | 2020-03-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-24 | 2020-03-27 | 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 | 2020-02-24 | 2020-03-27 | N |
| Provide activities to meet all resident's needs. | Health | 2020-02-24 | 2020-03-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-24 | 2020-03-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-24 | 2020-03-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-24 | 2020-03-27 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2020-02-24 | 2020-03-27 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2020-02-24 | 2020-03-27 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-02-24 | 2020-03-27 | N |
| Post nurse staffing information every day. | Health | 2020-02-24 | 2020-03-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-24 | 2020-03-27 | 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 | 2020-02-24 | 2020-03-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-24 | 2020-03-27 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2020-02-24 | 2020-03-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-02-24 | 2020-03-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-24 | 2020-03-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-24 | 2020-03-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-24 | 2020-03-27 | N |
| Meet other general requirements. | Fire Safety | 2020-02-25 | 2020-03-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-25 | 2020-03-15 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2020-02-25 | 2020-03-13 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2020-02-25 | 2020-03-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-25 | 2020-03-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-02-25 | 2020-03-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-25 | 2020-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-25 | 2020-03-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-08-23 | 2018-11-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-08-23 | 2018-11-01 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-08-23 | 2018-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-23 | 2018-11-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-08-23 | 2018-11-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-08-23 | 2018-11-01 | N |
| Provide or obtain dental services for each resident. | Health | 2018-08-23 | 2018-11-01 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2018-08-23 | 2018-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-23 | 2018-11-01 | N |
| Meet other general requirements. | Fire Safety | 2018-09-06 | 2018-09-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-09-06 | 2018-09-30 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-09-06 | 2018-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-06 | 2018-09-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-09-06 | 2018-09-30 | N |
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