Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lorien Health Systems Mt Airy during CMS and state inspections, most recent first.
Facility staff failed to accurately code MDS assessments for 4 residents. Errors included missed active diagnoses such as cancer and thrombocytopenia, failure to code high-risk meds including anticonvulsants and an anti-anxiety med, coding antidepressant use without MAR support, and missing nightly BiPAP use on the MDS.
Failure to provide ordered wound treatment. A resident with PVD had a wound on the second right toe, and the wound care NP changed the treatment orders to cleanse the wound, apply Skin Prep to the peri-wound area, and secure the dressing daily. Review of the MAR/TAR showed staff did not provide the ordered treatment for 5 days, and the DON confirmed the missed wound care.
A resident did not receive medications as ordered by the physician, with multiple doses administered several hours late or on the following day, contrary to facility policy requiring administration within one hour of the scheduled time. This deficiency was confirmed through medical record review and staff interviews.
The facility did not provide documentation that advance directives were reviewed with or information provided to two residents or their responsible representatives. In both cases, although some forms such as MOLST or POA were present, there was no evidence that AD information or education was given or discussed, as confirmed by staff interviews and record reviews.
A resident with a history of recurrent UTIs developed urinary retention after admission and required a urinary catheter and medication. Despite ongoing interventions, including voiding trials and a urology consult, staff did not update the care plan to address the resident's urinary retention and catheter care until the issue was identified by surveyors.
A resident who was dependent on a mechanical ventilator via tracheostomy was hospitalized for respiratory distress and returned to the facility. After a comprehensive assessment was completed post-hospitalization, the interdisciplinary team did not review or revise the care plan to address the resident's ongoing respiratory needs.
Surveyors found that two residents receiving supplemental oxygen had their oxygen tubing and humidifier bottles unlabeled and undated, despite physician orders requiring weekly changes and labeling. An LPN confirmed the omission, noting that night shift staff were responsible for labeling, and the DON acknowledged the issue as unacceptable.
A resident received PRN traMADol for severe pain, but documentation showed the medication was ineffective and there was no timely reassessment or additional interventions recorded. Nursing staff indicated that non-pharmacological interventions were not consistently documented, and the DON confirmed that pain reassessment was delayed.
A surveyor found an expired IV start kit in a medication cart during a review of medication storage and labeling. An RN confirmed the kit was expired and removed it immediately. The DON acknowledged the finding and stated that nurses and unit managers are responsible for checking for expired items, in accordance with facility policy.
Staff documented assessments and treatments for a resident after the individual had already been pronounced deceased and removed from the facility. The MAR and TAR reflected care activities as completed during evening and night shifts, despite the resident's death earlier that day. The DON confirmed the documentation was inaccurate, resulting in incomplete and inaccurate medical records.
Facility staff did not ensure that the social service director and medical director participated in required QAPI committee meetings, with both roles marked as on leave during certain months. No qualified designees were present for these positions, and the staff member covering for the social services director lacked appropriate training. The sign-in sheets did not show participation by a covering medical director.
Two residents in an LTC facility experienced verbal abuse from staff members. One resident, with a history of cognitive communication deficit, reported being verbally abused by a staff member, which was confirmed by a roommate. Another resident, with multiple sclerosis, reported a threatening comment from a staff member, corroborated by a witness. Both incidents were verified by the facility's investigation, leading to the termination of the involved staff members.
A medication administration error occurred when an RN prepared medications for two residents simultaneously, leading to one resident receiving medications intended for another. The affected resident, with a complex medical history, was given cardiovascular drugs and an anticoagulant not prescribed for them, resulting in a hospital transfer for monitoring. The facility's policy requiring resident identification before medication administration was not followed.
The facility failed to ensure proper care and monitoring of residents with PEG tubes, as evidenced by a complaint survey involving five residents. A resident's PEG tube became dislodged and was replaced by an RN, but the facility's policy lacked guidelines for confirming tube placement with an x-ray. Additionally, there were no documented physician orders for PEG tube size or monitoring in the medical records of several residents, highlighting inconsistencies in treatment orders and interventions for potential complications.
A medication administration error occurred when an RN prepared medications for two residents simultaneously and administered the wrong medications to a resident with a complex medical history. The resident received blood pressure-lowering drugs and an anticoagulant not intended for them, leading to hospitalization and episodes of tachycardia and bradycardia.
Inaccurate MDS Coding for Diagnoses, Medications, and BiPAP Use
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for 4 of 12 residents reviewed during a complaint survey. The deficiency involved inaccurate or incomplete coding in the MDS for active diagnoses, high-risk medications, and special treatments/procedures. The MDS is part of the Resident Assessment Instrument and is used to identify each resident’s individual needs so care can be planned based on those needs. For one resident with thrombocytopenia and a history of malignant neoplasm of the lip, oral cavity, and pharynx, the MDS assessments did not capture the cancer or thrombocytopenia despite physician documentation of critically low platelets and treatment for carcinoma of the buccal mucosa. For another resident with neuropathy receiving Gabapentin, the MDS failed to code Gabapentin as an anticonvulsant on two assessments. A third resident with multiple sclerosis, depression, mental disorders, and lumbar disc degeneration had MDS assessments that failed to capture Diazepam and Gabapentin as high-risk medications, and antidepressant use was coded even though the MARs did not show antidepressant administration. A fourth resident with cerebral infarction, convulsions, epilepsy, cervicalgia, cervical stenosis, and obstructive sleep apnea had MDS assessments that failed to capture anticonvulsant use, and one assessment also failed to code nightly BiPAP use documented on the TAR.
Failure to Provide Ordered Wound Treatment
Penalty
Summary
Facility staff failed to follow the wound care NP’s orders for a resident with peripheral vascular disease who had a wound on the second right toe. The resident was admitted in 2025 with PVD, and the facility first assessed the toe wound on 2/22/26 and began treatment. On 2/24/26, the wound care NP evaluated the resident and ordered treatment for the wound. On 3/3/26, the wound care NP reassessed the wound and changed the treatment orders to cleanse the wound with wound cleanser, apply Skin Prep to the peri-wound area, and secure the dressing daily. Review of the March 2026 MARs/TARs showed facility staff did not administer the ordered treatment to the right second toe wound from 3/3/26 through 3/7/26. The DON confirmed on 5/6/26 that the wound treatment had not been provided during that period.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered to a resident according to physician orders and facility policy. Medical record review and interviews confirmed that multiple medications were not given at the prescribed times over several days. Specifically, medications scheduled for administration at set times, such as 7:00 AM, 8:00 PM, and 11:00 PM, were instead given several hours late, with some doses administered the following day. The facility's policy requires medications to be given within one hour before or after the scheduled time unless otherwise specified by the physician, but this standard was not met for the resident in question. The deficiency was identified during a recertification and complaint survey, which included a review of the medication administration audit report and interviews with facility staff. Both the Unit Manager and the Director of Nursing confirmed the delays in medication administration for the resident during the specified period. The findings were based on direct evidence from the medication records and staff acknowledgment of the deviations from prescribed medication times.
Failure to Document Advance Directives Review and Education
Penalty
Summary
The facility failed to provide documentation that advance directives (AD) were reviewed with, or information and education regarding ADs were provided to, residents and/or their responsible representatives. For two residents, medical record reviews revealed either the absence of AD documentation or lack of evidence that discussions about ADs had occurred. In one case, although a MOLST form and a Power of Attorney document were present in the chart, there was no documentation to support that AD information was provided to the resident or their representative. Interviews with the Director of Nursing and the social work director confirmed that the required documentation was not available and that the family was being contacted to locate the AD. In another instance, a resident's medical record included a MOLST form indicating "No CPR, Option B, Palliative and Supportive Care," but no AD was found in the records, nor was there documentation of any discussion about ADs with the resident or their responsible party. Social services progress notes also lacked any mention of ADs. Staff interviews confirmed that the topic of ADs had not been addressed with the resident or their representative, and the facility's policy requiring inquiry and documentation of ADs upon admission was not followed for these residents.
Failure to Develop Comprehensive Care Plan for Urinary Retention and Catheter Use
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan to address a resident's urinary retention and use of a urinary catheter. The resident, who had a history of recurrent urinary tract infections (UTIs), was admitted without a urinary catheter but began experiencing difficulty urinating after admission. As a result, a urinary catheter was ordered and inserted, and the resident was placed on Flomax for urinary retention. Voiding trials were attempted but were unsuccessful, and a urology consult was ordered for ongoing urinary retention and chronic UTIs. Despite these interventions and changes in the resident's condition, there was no documented evidence that the care plan was updated to reflect the resident's urinary retention, catheter use, or the interventions being implemented, such as voiding trials. Interviews with staff confirmed that the care plan had not been updated to address these specific care needs until after the issue was identified by surveyors. The deficiency was identified through record review and staff interviews, which revealed a lack of timely and comprehensive care planning for the resident's urinary issues.
Failure to Revise Care Plan After Hospitalization and Change in Condition
Penalty
Summary
The facility failed to revise the care plan by the interdisciplinary team after each assessment for a resident who experienced a significant change in condition. Specifically, after a resident was hospitalized for respiratory distress and subsequently returned to the facility, a comprehensive assessment (MDS) was completed. However, there was no documented evidence that the care plan was reviewed and revised to address the resident's need for continuous mechanical ventilation related to respiratory insufficiency following the post-hospitalization assessment. Record review and interviews confirmed that the care plan was not updated after the resident's return from the hospital, despite the resident's dependence on a mechanical ventilator via tracheostomy. The DON acknowledged that the care plan should have been reviewed and revised as required, but this was not done after the most recent assessment.
Failure to Label and Date Oxygen Equipment for Residents Receiving Respiratory Care
Penalty
Summary
Surveyors observed that two residents receiving supplemental oxygen therapy had oxygen equipment, including humidifier bottles and oxygen tubing, that were not labeled or dated to indicate when they were last changed. Both residents had physician orders specifying that the oxygen tubing, nasal cannula, and humidifier bottles should be changed weekly and labeled with the date of change. During the survey, the equipment in both residents' rooms lacked any such labeling, and in one instance, the oxygen tubing was found lying on the floor. Staff interviews confirmed that the labeling had not been completed as required. An LPN acknowledged the omission and stated that the night shift was responsible for labeling the oxygen tubing, regardless of whether the oxygen was administered as needed. The DON was also informed of the issue and agreed that the lack of labeling was unacceptable. The deficiency was identified based on direct observation, record review, and staff interviews.
Failure to Timely Assess and Address Ineffective Pain Management
Penalty
Summary
A deficiency was identified when a resident with an order for PRN traMADol for pain was administered the medication for a reported pain level of 7 out of 10. Documentation showed that the medication was not effective in relieving the resident's pain. However, there was no evidence in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) that additional interventions were implemented or that the effectiveness of the pain medication was reassessed within the professional standard of one hour after administration. Interviews with nursing staff revealed that while non-pharmacological interventions such as ice packs might be offered, these were not consistently documented unless there was a physician's order. The Director of Nursing acknowledged that, based on available documentation, the reassessment of the pain medication's effectiveness was completed late, and additional interventions were not offered until several hours after the initial administration.
Expired IV Start Kit Found in Medication Cart
Penalty
Summary
During a recertification survey, facility staff failed to remove expired supplies from a medication cart. Specifically, an IV start kit with an expired date was found in the bottom drawer of Medication Cart #1 on the Prospect Unit. This was observed by a surveyor in the presence of a registered nurse, who confirmed the kit was expired and acknowledged it should not have been in the cart. The nurse immediately removed the expired kit upon discovery. The Director of Nursing (DON) was informed of the finding and confirmed awareness of the expired IV start kit. According to the facility's policy and procedure for storage of medications, no discontinued, outdated, or deteriorated drugs or biologicals should be available for use, and all such items are to be destroyed. The responsibility for checking medication carts for expired items was stated to rest with the nurses and unit managers.
Inaccurate Post-Mortem Documentation in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. A review of the closed medical record for a resident who had died revealed that staff documented assessments and treatments as having been performed during the evening and night shifts on the date of the resident's death, despite the resident having already been pronounced deceased and released to the funeral home earlier that day. Documentation included administration of medications, completion of assessments for pain, oxygen monitoring, bleeding/bruising precautions, and other routine care tasks, all recorded after the resident was no longer present in the facility. Further review of the nurses' progress notes confirmed the resident experienced a change in condition, was assessed by EMTs, and was pronounced dead in the early afternoon. The Director of Nursing verified that the documentation by evening and night shift staff was inaccurate, as the resident was not in the facility at the time the care was recorded as provided. This discrepancy demonstrates that the medical records did not accurately reflect the resident's status or the care provided, constituting a failure to safeguard resident-identifiable information and maintain records according to professional standards.
Failure to Ensure Required QAPI Committee Participation by Key Staff
Penalty
Summary
Facility staff failed to ensure that both the social service director and the medical director participated in the required monthly Quality Assessment Performance Improvement (QAPI) committee meetings. Review of QAPI sign-in sheets revealed that the medical director was on a leave of absence for certain months, and the social service director was also marked as on leave for other months. During these absences, there was no designated person for the medical director, and the only social services worker, who also served as the director, was absent. Staff stated that information from the QAPI meetings was shared with absent members during risk management meetings, but the sign-in roster did not reflect participation by a covering medical director. Additionally, the staff member who acted as the designee for the social services director did not have training in social services, and there was no qualified designee for the medical director during the periods of absence.
Verbal Abuse Incidents in LTC Facility
Penalty
Summary
The facility failed to protect residents from verbal abuse, affecting two residents. Resident #3, who had a history of pulmonary embolism, cognitive communication deficit, hypertension, and a history of falling, reported an incident where a staff member, Staff #110, used derogatory language towards them. The incident was corroborated by Resident #3's roommate, who confirmed hearing the abusive language. Despite the resident's attempt to engage with the staff member, the staff member repeated the abusive statement. The staff member involved refused to cooperate with the facility's investigation and was subsequently terminated. Another incident involved Resident #5, who had a medical history of multiple sclerosis and spinal stenosis. Resident #5 reported that Staff #111 made a threatening comment about pushing them out of their wheelchair. This incident was overheard by another resident, who confirmed the statement. The staff member involved denied making the comment but was reassigned pending investigation and later terminated. The facility's investigation verified the resident's report based on witness statements and the staff member's lack of cooperation. Both incidents were confirmed as verbal abuse by the facility's Director of Nursing and other staff members involved in the investigation. The facility's policy on abuse, which maintains zero tolerance for any form of abuse or neglect, was not adhered to in these cases, leading to the substantiation of the allegations. The facility took steps to investigate and address the incidents, but the deficiency was identified due to the initial failure to protect the residents from verbal abuse.
Medication Administration Error Due to Policy Violation
Penalty
Summary
The facility failed to administer medications according to its policy and standard nursing practice, specifically concerning the medication rights of residents. An incident occurred involving an RN who prepared medications for two different residents simultaneously, which led to a medication error. The RN mistakenly administered medications intended for one resident to another. This error was discovered when the RN realized she still had the medication for the first resident after leaving the room of the second resident. The facility's policy requires identification of the resident before medication administration, which was not followed in this instance. The affected resident, who had a complex medical history including diastolic congestive heart failure, atrial fibrillation, and diabetes mellitus, received medications intended for another resident. These medications included cardiovascular drugs and an anticoagulant, which were not appropriate for the resident's condition. The resident's vital signs prior to the medication administration indicated that a blood pressure medication should have been withheld, but due to the error, the resident received additional medications that could lower blood pressure. As a result, the resident was transferred to the hospital for monitoring and stayed for four days. The facility's Director of Nursing and Nursing Home Administrator were informed of these findings during the survey.
Deficiency in PEG Tube Care and Monitoring
Penalty
Summary
The facility failed to ensure proper processes were in place for the daily care and monitoring of residents with percutaneous endoscopic gastrostomy (PEG) tubes, as evidenced by a complaint survey involving five residents. The deficiency was highlighted by an incident involving a resident whose PEG tube became dislodged and was replaced by a staff RN. The replacement process included inflating the balloon with 15ml of water, as per the SBAR form, and confirming placement through aspiration and auscultation. However, the facility's policy lacked specific guidelines regarding the need for an x-ray to confirm tube placement, and there were no documented physician orders for the size of the PEG tube or directions for placement and monitoring in the resident's medical record. Further investigation revealed that other residents relying on PEG tubes for nutrition and medication administration also lacked documented orders for PEG tube replacement and monitoring. One resident had conflicting orders noting two different sizes of PEG tubes. Interviews with staff confirmed that physician orders should be in place for residents with PEG tubes, but the medical records reviewed did not reflect this. The deficiency was discussed with the facility's Director of Nursing, highlighting the inconsistency and lack of treatment orders and interventions for potential complications related to PEG tube care.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to administer medications to residents without significant medication errors, as evidenced by an incident involving a registered nurse (RN) who prepared medications for two different residents simultaneously. The RN mistakenly administered the medications intended for one resident to another. Specifically, the RN prepared medications for Resident #8 and Resident #12 at the same time and inadvertently gave Resident #12's medications, including three blood pressure-lowering drugs and an anticoagulant, to Resident #8. This error occurred despite the fact that Resident #8's vital signs indicated that blood pressure medication should have been withheld. Resident #8, who had a complex medical history including diastolic congestive heart failure, atrial fibrillation, and diabetes mellitus, was adversely affected by the medication error. Following the administration of the incorrect medications, Resident #8 was transferred to the hospital for monitoring, where they experienced episodes of tachycardia and bradycardia. The hospital recommended the placement of a pacemaker, but the family declined due to the resident's age. The incident was reviewed with the facility's Director of Nursing (DON) and Nursing Home Administrator (NHA) during the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mount Airy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mount Airy Nursing And Rehab Center | 1.2 mi | ★★★★★ | 31 | 0 |
| Copper Ridge Nursing And Assisted Living Center | 9.4 mi | ★★★★★ | 6 | 1 |
| Willowbrooke Court Skilled Care Center Fairhaven | 9.6 mi | ★★★★★ | 5 | 0 |
| Autumn Lake Healthcare At Birch Manor | 9.7 mi | ★★★★★ | 1 | 0 |
| Autumn Lake Healthcare At Ballenger Creek | 10.3 mi | ★★★★★ | 4 | 0 |
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