Mount Airy Nursing and Rehab Center

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure that residents remained free from sexual, physical, and verbal abuse, as well as intimidation by facility staff. This was evident for 3 (Residents #4, #1, and #5) of 4 residents reviewed for allegations of abuse related to facility reported incidents (FRIs #2987931, #2789533, and #3012852).

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to complete the required follow-through after a substantiated allegation of abuse involving a credentialed Geriatric Nursing Assistant and failed to thoroughly investigate allegations of physical and sexual abuse. This was evident for 3 of 4 residents (Resident #5, Resident #1, and Resident #4) reviewed for allegations of abuse related to facility reported incidents (FRI #2789533, #2987931, and #3012852).

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to include adverse event monitoring of alleged physical and sexual abuse in the facility's Quality Assurance and Performance Improvement (QAPI) activities. This was evident for 2 of 2 facility reported incidents (FRI #2670676 and #2686939) involving injuries of unknown origin and 4 of 4 facility reported incidents (FRI #2707002, #2787931, #2987931, and #3012852) involving allegations of abuse.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure timely reporting of an injury of unknown origin in accordance with facility policy and federal requirements. This was evident for 1 of 2 residents (Resident #1) reviewed for a facility reported incident (FRI #2670676) related to an injury of unknown origin.

Inspectors wroteBased on complaint, interviews with facility staff, and reviews of all pertinent administrative records, it was determined that the facility failed to provide Resident #1's representative with a copy of the Resident's #1 medical record in a timely manner. This was evident for 1 of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on interview and record review it was determined that the facility failed to provide activities for residents. This was evident for five residents (R #44, #45, #47, #50, #53) of seven residents reviewed for Activities during the recertification survey.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to 1) Ensure medications and treatment supplies were secured and stored properly for 4 of 6 medication/treatment carts observed, 2) Discard medications per manufacturer's instructions when opened beyond the recommended timeframe, and 3) Ensure staff consistently followed facility policy and practice for securing medication/treatment carts during the annual recertification survey.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review, observation, and interview it was determined that the facility failed to accurately assess residents' dental status. This was evident for one resident (Resident #69) of one resident reviewed for dental care during the recertification survey.

Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to ensure medication errors were below 5% during the medication administration observation. This was evident for 2 of 29 medications administered during the observation.

Inspectors wroteBased on observation and relevant document review, it was determined that the facility kitchen failed to provide residents with the meals as indicated on their meal tickets. This was evident for 3 residents (Resident #5, #65, and #33) out of 3 observed during a dinner dining observation.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to use proper infection control strategies. This was evident for 1) one of two laundry rooms observed, and 2) while providing feeding assistance to a resident(s).

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure call systems devices were within reach and available to the residents. This was evident for one (Resident # 60,) in a random observation during a survey.

Inspectors wroteBased on reviews of the resident's medical record and administrative records, and resident and staff interviews, it was determined that the facility staff failed to ensure a mechanical lift sling was properly positioned under a totally dependent Resident (#11) before initiating the transfer. This failure led to Resident (#11) sliding through the front of the lift sling onto the floor. This failure led to Resident (#11) being sent to the emergency room and being diagnosed with a fractured pelvis. This resulted in harm to Resident #11. This was evident for 1 (Resident #11) of 2 residents reviewed for accidents during an annual Long Term Care Survey Process. After the incident, the facility developed initiated, and completed a plan of correction to prevent further injuries to residents during care. Therefore, this deficiency will be cited as past non-compliance. [...]

Inspectors wroteBased on resident and staff interviews it was determined that the facility did not ensure that residents received mail on the weekend. This has the potential to affect all residents.

Inspectors wroteBased on review of facility records and interview with staff it was determined the facility failed to establish and implement a grievance policy to ensure resolution of all grievances and evidence demonstrating that the result of all grievances were maintained for no less than 3 years. This was evident during review of 1 (#MD00186812) of 8 complaints reviewed during the survey and had the potential to affect all residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to post the required Names, addresses, and telephone numbers for all pertinent State agencies and advocacy groups, such as the State Survey Agency. This was identified in one of the two facility buildings affecting up to 32 residents at the time of the survey.

Inspectors wroteBased on record review and staff interviews it was determined that the facility failed to have a system in place for notifying residents and their representatives in writing of their remaining Medicare benefit days. This was evident for 1 of (#39) of 3 residents reviewed for beneficiary notice.

Inspectors wroteBased on surveyor observation and staff interview it was determined the facility failed to provide housekeeping and maintenance services to maintain a safe, clean, and comfortable environment. This was evident in 1 of 2 buildings observed during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was identified for 4 (Resident #11, #34, #44, and #72) of 10 residents reviewed for hospitalization during the annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was identified for 4 (Resident #11, #34, #44, and #72, ) of 10 residents reviewed for hospitalization during the annual survey.

Inspectors wroteBased on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to 1) hold care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of their care plan and 2) failed to update a resident's care plan to reflect food preferences. This was evident for 3 (#39, #43, #58) of 57 residents reviewed during the annual survey.

Inspectors wroteBased on reviews of a medical record and staff interview, it was determined that the facility nursing staff failed to document a resident's care in the resident's medical record per nursing standards. This was evident for 1) 1 (Residents #11) of 8 residents reviewed for accurate medical records; and 2) for 1 (#1) of 5 residents reviewed for Advance directives during an annual recertification survey.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility staff failed to 1) maintain a resident's call bell within reach of the resident, 2) maintain the resident call system in working order in the B-building, and 3) identify a resident's nonfunctioning call bell and a missing restroom call bell cable. This was identified for the entire B-building that was observed during an annual recertification survey.

Inspectors wroteBased on observation and reviews of a medical record, it was determined that the facility staff failed to treat each resident in a dignified manner by pulling a resident backward down the hallway. This was evident for 1 (Resident #6) resident reviewed for dignity during the Long Term Care Survey Process annual recertification survey.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility 1) failed to ensure the resident/responsible party was offered the opportunity to develop an advance directive; 2) failed to ensure that 2 physicians' certificates of incapacity were obtained for residents; and 3) failed to have a copy of the Advance Directive readily accessible in the medical record. This was evident for 3 (#41, #43, and #1) of 5 residents reviewed for advance directives during the annual survey.

Inspectors wroteBased on reviews of a complaint, a closed medical record, administrative records, and staff interviews, it was determined that the facility staff failed to notify a resident's physician and family member regarding new complaints of pain in the right leg. This was evident for 1 (Resident #180) of 3 residents reviewed for pain management during the Long Term Care Survey Process annual recertification survey.

Inspectors wroteBased on a facility-reported incident, closed clinical record review, staff interview, and reviews of the facility abuse policy, it was determined that facility staff failed to ensure a resident was free of staff abuse. This was evident for 1 (Resident #40) of 14 residents reviewed for abuse during a long-term care survey process recertification survey.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 2 (#36 and #381) of 14 residents reviewed for abuse during the annual survey.

Inspectors wroteBased on a review of medical records, investigative documentation, and interviews, it was determined that the facility failed to have an effective system in place to ensure abuse allegations were thoroughly investigated to determine if abuse occurred and take appropriate action. This was evident for 5 (Resident #70, #36, #28, #430, and #65) out of 14 residents reviewed for abuse during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 1 (#34) of 10 residents reviewed for hospitalization during the annual survey.

Inspectors wroteBased on observation, medical record review, and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#43) of 5 residents reviewed for activities of daily living during the annual survey.

Inspectors wroteBased on medical record reviews and staff interviews, it was determined that the facility social work department failed to obtain a state-designated evaluation for a resident who was determined to have a mental disorder (MD) or intellectual disability (ID), or related condition. This was evident for 1 (Resident #12) of 2 residents reviewed for PASARR screening during the Long Term Care Survey Process annual recertification survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide residents with a copy of their baseline care plan and their admission medications. This was evident for 1 (#41) of 1 newly admitted resident reviewed for baseline care plans during the annual survey. This has the potential to affect all residents that are newly admitted to the facility.

Inspectors wroteBased on observation, medical record review, and staff interview, it was determined that facility staff failed to develop and initiate comprehensive, resident-centered care plans for residents timely. This was evident for 1 (#43) of 57 residents reviewed during the annual survey.

Inspectors wroteBased on a complaint, reviews of active and closed records, and staff interviews, it was determined that the facility staff failed to 1) document the nurse practitioner wound care orders and implement the wound orders for a resident, 2) and 3) administer an antibiotic to 2 residents as prescribed by the resident's physician. This was evident for 3 (Resident #180, #33, #12) of 3 residents reviewed for quality of care during an annual recertification survey.

Inspectors wroteBased on medical record review, staff interview, and observation, it was determined that the facility failed to provide/document foley catheter care. This was evident for 1 (#43) of 1 resident reviewed for Foley catheters during the annual survey.

Inspectors wroteBased on observation, record review, and staff interviews, it was determined that the facility failed to label oxygen and nebulizer tubing with a date. This was evident for 1 (#71) of 3 residents reviewed for respiratory care.

Inspectors wroteBased on review of a complaint, closed medical record review, administrative record review, and staff interviews, it was determined that the facility staff failed to address a resident's new complaint of pain in the right leg. This was evident for 1 (Resident #180) of 3 residents reviewed for pain management during the Long Term Care Survey Process annual recertification survey.

Inspectors wroteBased on reviews of presurvey payroll-based journal staff data reports, reviews of facility administrative records, and staff interviews, it was determined that the facility failed to have a Registered Nurse for at least 8 consecutive hours in a 24-hour period for 4 out of 17 days reviewed for sufficient and competent nursing staff during an annual recertification survey.

Inspectors wroteBased on the review of employee records and staff interview, it was determined that the facility failed to have documentation that Geriatric Nursing Assistants (GNA) were given a yearly performance review. This was evident for 1 of 6 GNA employee records (Staff #50) reviewed during the review for sufficient and competent nursing staffing task during an annual recertification survey.

Inspectors wroteBased on record review, and staff interviews, it was determined that the facility failed to accommodate residents' food preferences. This was evident for 1 (#58) of 3 residents reviewed for nutrition during the annual survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to document education was provided regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to staff who had not received the COVID-19 vaccine. This was evident for 3 (Staff #18, #19, and #20) out of 8 facility staff members reviewed for COVID-19 vaccinations during the survey.

Inspectors wroteBased on observation and staff interview it was determined the facility failed to keep a freezer unit in the A-building kitchen in safe operating condition. This was evident during the initial tour of the kitchen and during a subsequent visit.

Inspectors wroteBased on the review of employee records and staff interview, it was determined that the facility failed to have documentation that Geriatric Nursing Assistant's (GNA) were given 1) dementia management training, 2) a yearly performance review, and 3) training for GNA's that provide services to residents with cognitive impairments. This was evident for 6 of 6 GNA employee records (Staff #13, #23, #48, #49, #50, and #41) reviewed during the sufficient and competent nursing staffing task during an annual recertification survey.

Inspectors wroteBased on record review and resident, and staff interviews, it was determined that the facility failed to have a process in place to ensure that concerns and suggestions from the resident group were reviewed and responses provided to the group in writing. This was evident for 4 of 4 months of Resident Council meeting minutes reviewed during an annual recertification survey.

Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to post the staffing requirements at the beginning of each shift and failed to ensure the information was complete, accurate, and current. This was noted during intermittent observations during the survey. All residents and visitors have the potential to be affected by the non-compliance.

Inspectors wroteBased on review of medical record and interview with facility staff, it was determined that the facility failed to ensure that care plans were developed in a way that was person-centered, contained measurable goals, and accurately reflected the needs of each resident. This was evident for 8 (#5, #50, #7, #40, #4, #53, #82 and #62) of 29 residents reviewed during the investigation phase of the survey. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to evaluate the effectiveness of care plans, including residents' progress or lack of progress toward reaching the care plan goals. This was evident for 7 (#13, #46, #82, #53, #4, #30 and #40) of 29 residents reviewed during the investigative stage of the survey. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.

Inspectors wroteBased on interview with the facility's resident councils, interview with facility staff, and review of resident council minutes, it was determined that the facility failed to demonstrate that a response was given for grievances and recommendations made by the resident councils. This practice has the potential to affect all residents.

Inspectors wroteBased on observations and staff interview during facility environmental observations, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed in both buildings of the facility.

Inspectors wroteBased on surveyor observation, review of the medical record and interview with facility staff it was determined the facility staff failed to provide necessary respiratory care services for residents by failing to date label oxygen administration equipment, failing to maintain a nasal cannula in a sanitary manner, failing to administer oxygen as prescribed and failing to develop and update plans of care to address the resident's respiratory needs. This was evident for 3 (#7, #32 and #5) of 3 residents reviewed for Respiratory Care.

Inspectors wroteBased on staff interview, observations and review of medical record it was determined that the facility staff failed to have an effective quality assessment and assurance (QAA) program based on repeat deficiencies related to development and revision of care plans, medication storage, infection control and medical record accuracy. This was evident during the survey process and review of the Quality Assurance Program.

Inspectors wroteBased on surveyor observation and interview with staff, it was determined that the facility staff 1) failed to date label oxygen administration equipment for 2 (#7 & #32) of 2 residents reviewed for respiratory care, and 2) failed to label and store personal equipment in a hygienic manner in 3 of 5 resident bathrooms in building A.

Inspectors wroteBased on observation, record review and staff/resident interview, it was determined that the facility staff failed to allow residents to choose a schedule for sleeping and waking. Additionally, Resident #4 had a goal that scheduled activities of daily living (ADL) without consideration of the resident's preference. This was evident for 1 (#4) out of 54 residents reviewed for care plans.

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to ensure that physicians were notified of changes in resident conditions. This was evident for 1 (#62) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on interviews with the resident and staff, and review of the resident's record it was determined that the facility 1) failed to report a resident's allegation of missing property and report the results of their investigation to the state survey agency for 1 (#7) of 2 residents reviewed for Personal Property and 2) failed to report injuries of unknown origin to the state agency for 1 (#8) of 8 residents reviewed for activities of daily living.

Inspectors wrote2) A record review conducted on 2/26/19 revealed an entry made by LPN #2, on 2/3/19, that Resident #8 had a bruise noted to the left leg. Further review failed to find evidence that an investigation was conducted to determine the cause/origin of the injury. Further review found an entry made by LPN #5 on 2/4/19, revealed that the resident had a purplish discoloration on the right side of the vaginal area discovered by staff members during care, that day. However, further record review failed to find documentation that a thorough investigation was completed. The Director of Nursing (DON) and the Administrator acknowledged surveyor's findings on 2/26/19, prior to the exit meeting. [...]

Inspectors wroteBased on medical record review and staff interview, it was determined the the facility failed to orient, prepare, and document a resident's preparation for transfer to the hospital. This was evident for 2 (#46, #59) of 6 residents reviewed for hospitalization.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#50, #79) of 3 residents reviewed for activities.

Inspectors wroteBased on review of the medical record and interview with facility staff it was determined the facility staff failed to provide necessary behavioral healthcare and services to maintain the highest practicable well being for a resident with behavioral problems. This was evident for 1 (#7) of 4 residents reviewed for behavioral concerns.

Inspectors wroteBased on observation and review resident medical records, it was determined that the facility failed to monitor residents with dementia for specific behaviors related to their dementia diagnosis. This was evident for 1 (#62) of 4 residents reviewed for dementia care.

Inspectors wroteBased on medical record review the pharmacy failed to clarify the indications for use of 3 psychotropic medications during monthly medication review for 1 (#91) of 7 sampled residents for unnecessary medications.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to ensure a resident's medication regimen was free from unnecessary drugs by failing to assure medication orders had adequate parameters to indicate when to administer as needed medications for pain. This was evident for 1 (#50) of 2 residents reviewed for pain management.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to ensure that a resident's medication regimen was free from an unnecessary psychotropic medication by failing to adequately monitor a resident for behavior, side effects, or adverse consequences related to psychotropic medication use. This was evident for 2 (#46 and #4) of 6 residents reviewed for accidents. The facility also failed to adequately monitor residents for behaviors related to psychotropic medication use for 1 (#4) of 7 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation and staff interview it was determined the facility failed to properly store medications as evidenced by 1) failing to ensure that medication was properly labeled and dated in 1 of 2 medication rooms; and 2) failed to ensure medications were properly secured when unattended for 1 of 4 medication carts observed during the survey.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to ensure that residents receiving therapeutic mechanically altered diets were given food of the correct consistency based on the physician order. This was evident for 1 of 3 meal observations performed during the survey.

Inspectors wroteBased on resident observation, record review, and interview with facility staff, it was determined that the facility failed to maintain accurate resident medical records by 1) failing to have an order to discontinue a treatment that the resident was no longer receiving, 2) failing to clarify discrepancies for indications for use of 3 psychotropic medications and failing to document the reason for continuing current medication doses despite pharmacy recommendations to decrease the dose. This was evident for 3(#62, #4, and #91) of 54 residents reviewed during the investigation phase of the survey.

Inspectors wroteBased on observation and staff interview it was determined the facility failed to have the results of the last annual survey posted in the survey binders that were accessible to residents and the public. This was evident in two of two survey binders.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative and the Office of the State Long-Term Care Ombudsman in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 4 (#39, #74, #46, #50 ) of 6 residents reviewed for hospitalization. 1) A record review conducted on 2/22/19 at 1:48 pm revealed that Resident #39 was transferred recently to an acute care facility. Further review of the record failed to reveal any documentation to support that the state Ombudsman's office was notified of the transfer. 2) A medical record review for Resident #74 was conducted on 2/22/19 at 1:48 pm. [...]

Inspectors wroteBased upon medical record review for 1 (#39) of 8 residents reviewed for hospitalization the facility failed to provide documentation of the bed hold policy was given to the resident and/or resident representative when resident was transferred to the hospital.

Inspectors wroteBased on observation and interview with residents and staff, it was determined that the facility failed to maintain residents' dignity and privacy as evidenced by 1) residents dependent on staff for assistance with dining received minimal attention and no conversation, 2) residents' clothing protectors were placed without permission, 3) staff failed to knock before entering resident rooms for residents interviewed during the initial pool process, and 4) personal articles of clothing being labeled with resident names visible on the outside of the item. These failures were evident for 11 of 54 residents (#60, #8, #54, #59, #32, #22, #25, #32, #86, #53, and #250) reviewed during this survey.