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Complaint Investigation

Lorien Health Systems Mt Airy

February 20, 2025 · Mount Airy, MD · 705 Midway Avenue
Citations 2
CMS Rating 5/5
Beds 62
Provider ID 215335
Healthcare Facility
Lorien Health Systems Mt Airy
Mount Airy, MD  ·  View full profile →
Inspection Summary

LORIEN HEALTH SYSTEMS MT AIRY in MOUNT AIRY, MD — inspection on February 20, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF658
Few affected

215335

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.

215335

Form Approved OMB

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

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MOUNT AIRY, MD, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LORIEN HEALTH SYSTEMS MT AIRY or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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