Lorien Health Systems Mt Airy

F-F658

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 215335

F-F760

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 9 215335 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215335 B. Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lorien Health Systems MT Airy 705 Midway Avenue Mount Airy, MD 21771

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm 30428

Residents Affected - Few Based on the review of a complaint, medical records, facility policy and procedures and interview with staff, it was determined that the facility failed to have processes in place to ensure for the daily care and potential complications of residents' percutaneous endoscopic gastrostomy tubes (PEG inserting a feeding tube directly into the stomach through the abdominal wall). This was evident during the review of 5 (Residents #4, #6, #16, #17, #18) of 6 residents with PEG tubes secondary to a complaint during a complaint survey.

The findings include:

Review of the complaint #MD00203009 on 2/18/25 at 12:53 revealed concerns related to the care of and replacement of a PEG tube for Resident #6 after it inadvertently came out. After the replacement of Resident #6's PEG tube on 2/3/24, the complainant reported that according to the hospital, there was too much water

in the balloon and that s/he was vomiting repeatedly, that's why the family requested the x-ray.

Further review currently revealed diagnosis of Resident #6 including admission post anoxic brain injury (a condition where the brain is deprived of oxygen for a prolonged period, leading to damage or death of brain cells), dysphagia (difficulty swallowing-unable) and gastrostomy status.

According to the complaint, on 2/3/24 Resident #6's PEG tube came dislodged and was replaced by staff RN #54 with a 20 French PEG tube and inflated with a 15ml balloon as per the SBAR (situation, background, assessment, recommendation) form completed on 2/3/24 at 11:50 AM. The on-call physician was notified prior to the replacement of the PEG tube and again after. Staff #54 requested an x-ray to confirm placement of the PEG tube at the family request as documented in the progress notes.

RN #54 was interviewed on 2/19/25 at 3:10 PM. She recalled the occurrence and replaced the PEG tube in Resident #6. When asked how to determine when a PEG tube can be replaced, she stated that it should be

in the physician orders along with the size of the PEG tube additionally it will state it on the PEG tube package. Regarding the tube placement with Resident #6, she stated that to check placement she aspirated and pushed air in and auscultated to confirmed placement, additionally with another nurse confirmed placement all as per the facility policy.

The facility policy was reviewed at this time. There was no date on the Gastrostomy and Jejunostomy Tubes policy. According to the policy, there was nothing regarding the need for an x-ray to confirm placement.

The DON was notified of the concern that the Gastrostomy policy had no date on 2/20/25

Interview with LPN #68 on 2/19/25 at 8:27 AM regarding the care of and replacement of a PEG tube. She stated that there are orders in the computer for each resident regarding what to do. Further she stated that you need physician orders to replace the PEG tube. Additionally, the PEG package tells you how much water to put in the balloon.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 215335 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215335 B. Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lorien Health Systems MT Airy 705 Midway Avenue Mount Airy, MD 21771

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 An interview completed on 2/19/25 at 8:49 AM with RN #107 revealed the same process as RN 54 and LPN #68, that you need a physician order that should already be in the system for residents that reside in the Level of Harm - Minimal harm or facility with PEG tubes. She further stated that getting x-rays are up to the physician, placement is checked potential for actual harm by aspiration and auscultation.

Residents Affected - Few Review of the medical record for Resident #6 on 2/20/25 at 9:55 AM failed to reveal any orders for the size of residents PEG tube or directions for placement and monitoring, except for the order that was called in on 2/3/24 when the tube inadvertently came out.

Review on 2/20/25 at 10:15 AM for Residents #16, #17 and #18 all who rely on PEG tubes for nutrition and medication administration all had no orders for PEG tube replacement and monitoring. Resident #4 had 2 orders in place noting 2 different sizes of PEG tubes in place. These concerns were reviewed with the facility DON on 2/19/25 at 10:25 AM.

The concern for the inconsistency with lack of treatment orders and interventions for potential complications and documentation of the size of the PEG tube and balloon were reviewed throughout the survey and again

during exit on 2/20/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 215335 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215335 B. Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lorien Health Systems MT Airy 705 Midway Avenue Mount Airy, MD 21771

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or 30428 potential for actual harm Based on the review of a facility reported incident, record review, interview with staff and observations, it was Residents Affected - Few determined that the facility failed to administer medications to residents without any significant medication errors. This was evident for 1(Resident #8) of 3 residents reviewed related to medication administration.

The findings include:

Review of the facility reported incident MD00190869 on 2/18/25 at 10:37 AM revealed a concern related to

an RN, identified as staff #108, who admitted that on 4/2/23 she prepared medications for 2 different residents, #8 and #12 at the same time. RN #108 then proceeded to the room of Resident #8 with both medicine cups, respectively labeled for each resident. According to the statement from staff #108 included in

the facility investigation packet, as she left the room for Resident #8 and proceeded to the room for Resident #12, it was then she realized that she still had the medicine for Resident #8 and that she had administered

the medication for Resident #12 to Resident #8.

Medical record review for Resident #8 revealed diagnosis to include diastolic congestive heart failure, presence of prosthetic heart valve, atrial fibrillation, history of cerebrovascular accident (a sudden interruption of blood flow to the brain), mitral valve insufficiency and diabetes mellitus. Resident #8 was also ordered one blood pressure medication with parameters ordered to hold for a low heart rate or systolic reading below 110 mm/hg.

On 4/2/23, Resident #8, had vital signs taken prior to medication administration as per protocol and physician orders. The results were 105/68, below the administration parameter, so the nurse was to hold the blood pressure lowering medication.

Resident #12, according to medical records reviewed on 2/18/25, had diagnoses to include a history of a cerebrovascular accident and venous embolisms. Resident #12 also ordered multiple cardiovascular medications and an anticoagulant.

On 4/2/23, RN #108 administered 3 blood pressure lowering medications to Resident #8 who, it was already determined should not receive any, in addition Resident #8 received Resident #12's ordered anticoagulant ( blood thinner, when not ordered can lead to a serious risk of bleeding, which can be dangerous and even life-threatening).

Resident #8 after notification to the physician of the medication error, was transferred to the hospital for monitoring where s/he stayed for 4 days. While in the hospital Resident #8 was documented as having repeated episodes of tachycardia (fast heartbeat over 100) and bradycardia (heart rate below 60) with recommendations for the placement of a pacemaker (implantable medical device that helps regulate the heart's rhythm by sending electrical impulses to the heart muscle), though the family declined secondary to

the resident's age.

Staff LPN #68 and Staff RN #107 were observed for medication pass and interviewed on 2/19/25. They both stated that 'no' you do not prepare more than one resident medication at a time, and it was not observed in progress or occurring during the complaint survey.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 215335 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215335 B. Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lorien Health Systems MT Airy 705 Midway Avenue Mount Airy, MD 21771

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 The findings and concerns were reviewed with the facility DON and NHA throughout the survey and again

during exit on 2/20/25. Level of Harm - Minimal harm or potential for actual harm cross reference