Lorien Health Systems Mt Airy
Inspection Findings
F-Tag F0578
Federal health inspectors cited LORIEN HEALTH SYSTEMS MT AIRY in MOUNT AIRY, MD for a deficiency under regulatory tag F-F0578 during a standard health inspection conducted on 2025-08-13.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of LORIEN HEALTH SYSTEMS MT AIRY.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-12.
F-Tag F0656
Federal health inspectors cited LORIEN HEALTH SYSTEMS MT AIRY in MOUNT AIRY, MD for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-08-13.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of LORIEN HEALTH SYSTEMS MT AIRY.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-12.
F-Tag F0657
Federal health inspectors cited LORIEN HEALTH SYSTEMS MT AIRY in MOUNT AIRY, MD for a deficiency under regulatory tag F-F0657 during a standard health inspection conducted on 2025-08-13.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of LORIEN HEALTH SYSTEMS MT AIRY.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-12.
F-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
Based on a complaint, medical record review, and interview, it was determined the facility failed to ensure staff followed physician orders as evidenced by failure to ensure residents receive medications as ordered by the physician. This was evident for 1 (Resident #69) of 37 residents reviewed during a recertification/complaint survey. The findings include:On 8/8/2025 at 11:26 AM, review of a complaint #365844 revealed that Resident #69's medicines were not given as prescribed.On 8/11/2025 at 8:11 AM, a
review of Resident #69's Medication Administration Audit Report from 4/3/2025 through 4/9/2025 for actual times meds were given revealed the resident's meds were not given as scheduled on the following dates/time:- On 4/3/2025: Med [Tizanidine HCL 4 mg tab ordered for 23:00 (11:00 PM) was given on the next day (4/4/2025) at 06:40 (6:40 AM)] - more than 7 hours past the scheduled time.- On 4/3/2025: Meds scheduled for 20:00 (8:00 PM) were given on the next day (4/4/2025) at 06:40 (6:40 AM).- On 4/4/2025: Pain med scheduled for 20:00 (8:00 PM) was given at 23:44 (11:44PM); more than 3 hours late.- On 4/6/2025: Meds scheduled for 07:00 (7:00 AM) were given at 14:55 (2:55 PM), 15:05 (3:05 PM), and 15:35 (3:35 PM) respectively.- On 4/9/2025: Meds scheduled for 07:00 (7:00 AM) were given at 12:46 PM.On 8/11/2025 at 10:16 AM a review of the facility's policy and procedure for Administration of Drugs revealed
the following It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Under procedure: 7). Medications must be administered within one (1) hour before or
after their prescribed time. (Note: before meals = one hour before meals, after meals=two hours after the end of meals). and 9). Unless otherwise specified by the resident's attending physician, routine medications should be administered as scheduled.On 8/11/2025 at 9:19 AM an interview was conducted with the Unit Manager (UM #12) for Prospect Unit, in the presence of the Director of Nursing (DON): Regarding medication administration times, UM #12 stated that meds that have a specific time scheduled to be given were expected to be given either an hour before or an hour after the scheduled time. For example, a med scheduled for 7:00 AM could be given as early as 6:00 AM and/or as late as 8:00 AM.Surveyor reviewed Resident 69's medication administration times for 4/3/2025 through 4/9/2025 with UM #12 and the DON.
They both verified and confirmed that there was a delay in Resident #69's med administration on the aforementioned dates. DON stated that they were working with the nursing staff to address issues regarding delays in medication administration to residents.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
F-Tag F0695
Federal health inspectors cited LORIEN HEALTH SYSTEMS MT AIRY in MOUNT AIRY, MD for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-08-13.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of LORIEN HEALTH SYSTEMS MT AIRY.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-12.
F-Tag F0697
Federal health inspectors cited LORIEN HEALTH SYSTEMS MT AIRY in MOUNT AIRY, MD for a deficiency under regulatory tag F-F0697 during a standard health inspection conducted on 2025-08-13.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe, appropriate pain management for a resident who requires such services.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of LORIEN HEALTH SYSTEMS MT AIRY.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-12.
F-Tag F0761
Federal health inspectors cited LORIEN HEALTH SYSTEMS MT AIRY in MOUNT AIRY, MD for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-13.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: 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.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of LORIEN HEALTH SYSTEMS MT AIRY.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-12.
F-Tag F0842
Federal health inspectors cited LORIEN HEALTH SYSTEMS MT AIRY in MOUNT AIRY, MD for a deficiency under regulatory tag F-F0842 during a standard health inspection conducted on 2025-08-13.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of LORIEN HEALTH SYSTEMS MT AIRY.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-12.
F-Tag F0868
Federal health inspectors cited LORIEN HEALTH SYSTEMS MT AIRY in MOUNT AIRY, MD for a deficiency under regulatory tag F-F0868 during a standard health inspection conducted on 2025-08-13.
Category: Administration Deficiencies
The facility was found deficient in the following area: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of LORIEN HEALTH SYSTEMS MT AIRY.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-12.
LORIEN HEALTH SYSTEMS MT AIRY in MOUNT AIRY, MD inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.