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Inspection visit

Inspection

LORIEN MAYS CHAPELCMS #21535130 citations on this visit
30 citations recorded

Citations

30 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0623GeneralS&S Dpotential for harm

    F623 - Transfer and discharge-

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  • 0689GeneralS&S Dpotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0711GeneralS&S Dpotential for harm

    F711 - Physician Visits

    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

  • 0759GeneralS&S Dpotential for harm

    F759 - Medication Errors

    Ensure medication error rates are not 5 percent or greater.

  • 0577GeneralS&S Epotential for harm

    F577 - The resident has the right to-

    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

  • 0580GeneralS&S Dpotential for harm

    F580 - Notification of Changes

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0584GeneralS&S Dpotential for harm

    F584 - Safe Environment

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0657GeneralS&S Epotential for harm

    F657 - Comprehensive Care Plans

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0679GeneralS&S Dpotential for harm

    F679 - Activities

    Provide activities to meet all resident's needs.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0726GeneralS&S Dpotential for harm

    F726 - Nursing Services

    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

  • 0730GeneralS&S Dpotential for harm

    F730 - Regular in-service education

    Observe each nurse aide's job performance and give regular training.

  • 0732GeneralS&S Epotential for harm

    F732 - Nurse Staffing Information

    Post nurse staffing information every day.

  • 0757GeneralS&S Dpotential for harm

    F757 - Unnecessary Drugs—General

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

  • 0758GeneralS&S Dpotential for harm

    F758 - Medication Errors

    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  • 0770GeneralS&S Dpotential for harm

    F770 - Laboratory Services

    Provide timely, quality laboratory services/tests to meet the needs of residents.

  • 0804GeneralS&S Epotential for harm

    F804 - Food and drink

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • 0812GeneralS&S Epotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0842GeneralS&S Dpotential for harm

    F842 - Resident-identifiable information

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0880GeneralS&S Dpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0100GeneralS&S Dpotential for harm

    Meet other general requirements.

  • 0232GeneralS&S Dpotential for harm

    Have corridors or aisles that are unobstructed and are at least 8 feet in width.

  • 0293GeneralS&S Dpotential for harm

    Have properly located and lighted "Exit" signs.

  • 0353GeneralS&S Dpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0363GeneralS&S Dpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0712GeneralS&S Epotential for harm

    F712 - Frequency of physician visits

    Have simulated fire drills held at unexpected times.

  • 0919GeneralS&S Dpotential for harm

    F919 - Resident Call System

    Meet requirements for the use of electrical equipment.

  • 0923GeneralS&S Epotential for harm

    F923 - Have adequate outside ventilation by means of windows, or mechanical

    Have proper medical gas storage and administration areas.

FAQ · About this visit

Common questions about this visit

What happened during the February 24, 2020 survey of LORIEN MAYS CHAPEL?

This was a inspection survey of LORIEN MAYS CHAPEL on February 24, 2020. The surveyor cited 30 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at LORIEN MAYS CHAPEL on February 24, 2020?

Yes, 30 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before tran..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.