Lorien Mays Chapel

Based on observation and staff interviews it was determined that the facility failed to maintain a safe and effective system for securing medication located in their designated treatment carts on nursing units.

This practice was observed on both units of the facility involving 3 of 4 of the posted treatment carts.

The findings include; During tour on the morning of 10/7/25 at approximately 8:00 AM on the 3rd floor, surveyor passed a treatment cart with a silver lock sticking out.

This surveyor continued down the hall for the intended destination and noted that the resident was eating.

This surveyor back tracked to the treatment cart and noted that it still had the silver lock protruding out.

This surveyor attempted to open the top drawer, and it easily opened.

Inside was hydrocortisone cream, bio freeze gel, nystatin powder all labeled with identifying resident names.

While this surveyor was looking through the drawers, a staff member came out of the room adjacent to the treatment cart, looked at me and pushed the cart over so she could get out of the room with her linen carts, then proceeded on her way.

During this time of perusing the treatment cart, the nurse at the medication cart could be heard having some issues with the computer.

She waved to the unit manager (UM) to come over to assist her.

This surveyor continued for another 12 minutes to stand at the cart and go through the drawers with no one questioning who I was or asking if I was in need of some assistance.

This surveyor walked down the hall to where the UM was located.

Upon approaching the UM at 8:14 AM, later identified as staff #0, another treatment cart was observed located behind where the UM was standing, this cart too was unlocked.

This surveyor then proceeded to peruse through this cart as well and write down what was inside, including, Orajel (numbing oral pain reliever), Anasep gel (antimicrobial gel), nystatin powder (antifungal topical powder), Silvasorb gel (antimicrobial cream), all prescribed and labeled for individual resident use.

The surveyor notified the staff UM #9 of the concerns at 8:18 AM and proceeded to the 2nd floor.On the second floor noted outside room # 211 with an employee water bottle on top.

There were multiple staff members around, including nursing and GNA's.

This surveyor proceeded to peruse this treatment cart as well and identified the same medications; Aspercreme, nystatin powder, hydrocortisone cream, some were noted as house stock while mist medications were individually ordered and prescribed to residents. It was not until I turned my back that a nurse in the area locked the cart and walked away down the hall.

This surveyor proceeded down the 2nd floor hallway and identified another treatment cart, this one was locked, the only 1 of 4 treatment carts in the facility locked without surveyor interventions.

This surveyor met with the facility DON at approximately 11:30 AM and updated her on the surveyors' observations.

She was made aware of the 3 unlocked treatment carts found in the facility and the concern that when staff were around, they did not question this surveyor's presence and reasoning for going through the treatment cart.

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

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