Mt Airy Gardens Rehabilitation and Nursing Center

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a clean and sanitary kitchen. This affected all residents except for three residents (#31, #57 and #66) who were identified by the facility as not receiving any food from the kitchen. The facility census was 91.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure the kitchen was free of pests. This affected all residents except for three residents (#31, #57 and #66) who were identified by the facility as receiving no food from the kitchen. The facility census was 91.

Inspectors wroteBased on observation, staff interview, review of a scoop size chart, and review of dietary spreadsheets, the the facility failed to ensure appropriate portion sizes were served. This had the potential to affect all 77 residents in the facility. The facility census was 77.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to store and handle food in a manner to prevent the potential spread of foodborne illness. This had the potential to affect all 77 residents in the facility. The facility census was 77.

Inspectors wroteBased on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure catheter bags were covered. This affected two (Residents #235 and #236) of three residents reviewed for catheters. The facility census was 77.

Inspectors wroteBased on medical record review, observation, staff interview, resident interview, and review of the facility policy, the facility failed to ensure a safe, clean and homelike environment. This affected one (Residents #59) of four residents reviewed for physician environment and had the potential to affect two (Residents #27 and #238) of seven residents residing on the Heritage nursing unit. The facility census was 77 residents.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately. This affected three (Residents #77, #8, #51) of four residents reviewed for MDS assessment accuracy. The facility census was 77 resident.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure completion of significant change Preadmission Screening and Resident Reviews (PASARRs.) This affected one (Resident #28) of two residents reviewed for PASARR status. The facility census was 77 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure care plans were updated to accurately reflect resident health care status. This affected one (Resident #72) of three residents reviewed for care plans. The facility census was 77 residents.

Inspectors wroteBased on medical record review observations, staff interviews and policy review, the facility failed to ensure timely suture removal. This affected one Resident (#73) of the one resident reviewed for facial lacerations. The facility census was 77.

Inspectors wroteBased on medical record review, observation, staff interview, and resident interview, the facility failed to ensure residents received care and services for management of contractures and impaired mobility. This affected three (Residents #9, #72, #51) of three residents reviewed for range of motion services. The facility census was 77 residents.

Inspectors wroteBased on medical record review, observation and staff interviews, the facility failed to ensure residents had fluids available at bedside. This affected one Resident (#08) reviewed for hydration. The facility census was 77.

Inspectors wrote3) Review of the medical record of Resident #06 revealed an admission date of 01/05/22. Diagnoses included dementia with agitation, memory deficit following cerebrovascular disease, type 1 diabetes, history of traumatic brain injury, post-traumatic stress disorder, unspecified convulsions, anxiety, depression, violent behavior, and mood disorder. Review of the physician orders for Resident #06 revealed an order dated 12/23/24 to check laboratory results (labs), including a Depakote level. The frequency of the need for the labs was not specified. Further review of physician orders revealed orders dated 01/07/22 for Depakote tablet Delayed Release (DR) 500 milligrams (mg) twice per day for unspecified convulsions and 08/01/24 for Rexulti (atypical antipsychotic) Oral Tablet two mg one time a day for dementia with agitation. [...]

Inspectors wroteBased on medical record review, observation and staff interviews, the facility failed to ensure medications were stored in accordance with professional standards. This affected one Resident (#237) of four resident reviewed for medication administration. The facility was 77.

Inspectors wroteBased on medical record review, staff interview, review of hospice plan of care and hospice contract, the facility failed to jointly collaborate to develop a comprehensive plan of care that identified services to be provided by both providers. This affected one Resident (#08) of two reviewed for hospice services. The facility census was 77.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the resident bedrooms provided full visual privacy. This affected one (Residents #8) of four residents reviewed for physical environment. The facility census was 77 residents.

Inspectors wroteBased on observation, family interview, and staff interview, the facility failed to ensure residents had a safe, clean, comfortable environment. This affected one (Resident #8608) and eight additional residents (#29, #30, #4, #5, #10,#11, #14 and #15) of nine residents' rooms observed. The facility census was 81.

Inspectors wroteBased on record review, hospital record review, staff interview, and policy review, revealed the facility failed to ensure residents medications were ordered and administered following a hospital discharge resulting in a significant medication error. This affected one (#11) of three Residents (#11, #12, and #13) reviewed of use of anti-coagulants. The facility census was 83.

Inspectors wroteBased on observations, review of medical record reviews, interviews with resident and facility staff, and review of facility policy, the facility failed to ensure staff provided adequate supervision to prevent a resident, who had been previously assessed as being at high risk of elopement, from leaving the facility unsupervised. This resulted in Immediate Jeopardy when one resident (#26) was placed at potential risk for serious life-threatening harm and/or injury when he eloped from the facility without staff knowledge. Resident #26 was missing for an unknown amount of time and was found by an off-duty employee approximately 0.1 miles from the facility ambulating with a wheeled walker in the middle of a busy, heavily trafficked street, and cars were having to swerve around the resident to avoid hitting him. This affected one (#26) of three residents reviewed for risk of elopement. [...]

Inspectors wroteBased on observations, staff interviews, resident interviews, record review, and review of the facility policy, the facility failed to ensure the elevators were maintained in good working order and failed to ensure cigarette butts were disposed of in appropriate containers. This had the potential to affect all residents residing in the facility except the 27 residents who resided on the secured unit of the facility. The facility census was 89.

Inspectors wroteBased on medical record review, review of the facility policy, and staff interview, the facility failed to timely notify the resident's representative of a resident's elopement from the facility. This affected one (Resident #26) of three residents reviewed for notification of change. The facility census was 88.

Inspectors wroteBased on record review, review of the facility policy, and staff interviews, the facility failed to ensure there was an interdisciplinary team for the resident's care conference meetings. This affected four residents (Residents #5, #7, #26, and #67) of four residents reviewed for care planning and care conferences. The facility census was 88.

Inspectors wroteBased on observation, interview, and record review the facility failed to have handrail tightly and properly attached to walls. This had the potential to affect 58 Residents (#1, #2, #3, #4, #5, #6, #7, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57 #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, and #81) identified by the facility as being independently mobile. The facility census was 74.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the resident care environment was free of accident hazards. This had the potential to affect the 21 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21) who resided on the secured dementia unit and were identified by the facility as being confused and able to ambulate or propel themselves independently. The facility census was 74.

Inspectors wroteBased on observations, staff interviews, and review of facility policies, the facility failed to ensure resident rooms and common areas were clean and well-maintained. This had the potential to affect the 21 residents (#1, #2, #3, #4, #5, #6. #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21) who resided on the secured dementia unit. The facility census was 74.

Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to provide adequate preparation for resident transfer/discharge from the facility. This affected one resident (Resident #70) out of three residents reviewed for transfers and discharges. The facility census was 74.

Inspectors wroteBased on record review, observation, staff interview, review of hospital record, review of the facility policy, and review of the online resources the facility failed to implement COVID-19 isolation precautions during resident smoke breaks for Resident #315 which had the potential to affect four residents (#04, #35, #59, #60). The facility failed to perform proper hand hygiene during meal tray pass which had the potential to affect the 24 residents residing on the dementia unit. Also, the facility failed to implement their tuberculosis (TB) control plan for four newly hired employees (Dietary #380, State Tested Nursing Assistant (STNA) #530, Licensed Practical Nurse (LPN) #605 and STNA #640) of nine newly hired employees since the last annual reviewed for having two-step tuberculin skin tests (TSTs). This had the potential to affect all residents residing in the facility. [...]

Inspectors wroteBased on observations, medical record reviews, staff and resident interview, and review of facility policy, the facility failed to ensure residents received services to accommodate needs and preferences related to room arrangements allowing access to their environment independently, for accessing their call lights when needed and access to their eyeglasses. This affected five (#12, #18, #55, #57, and #165) of five reviewed for accommodation of needs. The facility census was 63.

Inspectors wroteBased on observations, medical record reviews, staff interviews, activity calendar review and policy review, the facility failed to ensure activities were provided for cognitively impaired residents. This affected four (#19, #27, #46, and #57) of six residents on the unit reviewed for activities during the annual survey. The facility identified 24 residents residing on the unit. The facility census was 63.

Inspectors wroteBased on observation, medical reocrd review, staff and resident interview, review of the water temperature logs, and review of the facility's policy, the facility failed to ensure the resident environment was free of accident hazards, including maintaining hot water temperatures was within the recommended range, ensure a resident at high risk for aspiration was supervised during meals and resident's falls were investigated. This affected two (Resident #12 and #32) of 24 residents reviewed for accident hazards, one (Resident #33) of one resident reviewed for supervision of meals, and two (Resident #70 and #169) of four residents reviewed for falls. The facility census was 63.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to ensure the food was stored and prepared under sanitary conditions consistent with professional standards for food service safety. This had the potential to affect all 61 residents who received meals from the kitchen. The facility identified two residents (#52 and #63) who received enteral feedings only. The facility census was 63.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident's advanced directive was accurately recorded in all locations of the medical record to ensure the resident's wishes would be followed as directed in the event of an emergency. This affected two (#17and #65) of two residents reviewed for advanced directives. The facility census was 63.

Inspectors wroteBased on medical record review, staff interview, and review of facility documents, the facility failed to ensure the resident's physician documented reasons for resident discharge from the facility in the medical record. This affected one (#169) of four residents reviewed for discharge. The census was 63.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure resident assessments included accurate resident body weights. This affected one (#55) of five residents investigated for nutrition. The census was 63.

Inspectors wroteBased on medical record review and staff interviews, the facility failed notify the state mental health authority when a resident with a mental illness had a change of condition and was admitted to hospice. This affected one (#9) of two residents reviewed for significant change Pre-admission Screening and Resident Review (PASARR). The facility census was 63.

Inspectors wroteBased on observations, record review, and staff interview, the facility failed to provide assistance to a resident who was dependent on staff for grooming and dressing. This affected one (#57) of three residents reviewed for activities of daily living. The facility census was 63.

Inspectors wroteBased on observation, record review, staff interview, and review of the facility's policy, the facility failed to ensure each resident with a limited range of motion received appropriate treatment and services, including the use of splinting devices, to increase their range of motion and/or to prevent decline. This affected two residents (#33 and #52) of five residents reviewed for limited range of motion. The facility identified 16 residents with contractures. The facility census was 63.

Inspectors wroteBased on record review, observation, staff interview, and review of the facility's policy, the facility failed to appropriately monitor a resident's dialysis access site. This affected one (Resident #3) of one resident reviewed for dialysis. The facility identified three residents receiving dialysis services. The facility census was 63.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to administer medications as ordered by the physician. This affected two (Residents #169 and #52) of 26 residents sampled. The census was 63.

Inspectors wroteBased on medical record review, review of the hospital records, staff interview, review of online medication resource Medscape, and policy review, the facility failed to appropriately monitor residents for the administration of anticoagulant and anti-seizure medication. This affected two residents (#55 and #52) of six residents reviewed for unnecessary medications. The census was 63.

Inspectors wroteBased on medical record review, staff interview, review of the online medication resource Medscape, and policy review the facility failed to ensure the use of antipsychotic medications appropriately. This affected two residents (#55 and #64) of six residents reviewed for unnecessary medications. The census was 63.

Inspectors wroteBased on medical record review, review of the hospital records, staff interview, review of online medication resource Medscape, and policy review, the facility failed to administer anticoagulant medication as ordered by the physician resulting in a significant medication error. This affected one resident (#55) of six residents reviewed for unnecessary medications. The census was 63.

Inspectors wroteBased on record review, observation, resident interview, staff interview, and review of facility documents and policy, the facility failed to provide resident with a snack when he went to outpatient dialysis treatments. This affected one resident (#3) of one reviewed for dialysis. The census was 63.

Inspectors wroteBased on medical record review, observation, review of the dietary tray card, and staff interview, the facility failed to ensure that each resident's medical record contained accurately documented information regarding nutritional supplements ordered and provided, skin care documented, and care planned advanced directive information. This affected three (#33 and #169) residents of 26 resident records reviewed.

Inspectors wroteBased on medical record review, observation, and interview the facility failed to ensure a resident had a working call light. This affected one (#215) of 26 residents reviewed.

Inspectors wroteBased on personnel file review, education record review and staff interview, the facility failed to ensure adequate nurse aide in-servicing was provided based on performance review. This had the potential to affect all 87 residents residing in the facility.

Inspectors wrote4. Review of the medical record revealed Resident #25 was admitted on [DATE]. Diagnoses included chronic kidney disease, schizoaffective disorder, diabetes mellitus, morbid obesity, antisocial personality disorder, diabetic neuropathy, conversion disorder, chronic obstructive pulmonary disease, delusional disorders, heart failure, mastopathy of unspecified breast, chronic respiratory failure with hypoxia, bipolar disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition, displayed no verbal or physical behavioral symptoms or rejection of care, and required supervision for activities of daily living (ADL's). Further review of Resident#25's medical record revealed the pharmacist conducted monthly regimen reviews from 10/2018 through 02/2019. [...]

Inspectors wroteBased on medical interview, observation, resident and staff interview and facility policy review the facility failed to ensure a resident was treated in a dignified manner in regards to leaving a hospital bracelet on. This affected one Resident (#67) of one reviewed for dignity. The facility census was 87.

Inspectors wroteBased on medical record review, resident fund account review and staff interview, the facility failed to notify Medicaid residents when the amount in their resident's funds account reached 200 dollars of the eligibility limit. This affected two (#29 and #75) of five residents reviewed for resident funds accounts.

Inspectors wroteBased on medical record review, hospital record review, observation, staff interview and facility policy review, the facility failed to notify each resident's physician when there was a significant weight loss and a need to alter nutrition interventions. This affected one Resident (#65) of five reviewed for nutrition. The facility census was 87.

Inspectors wroteBased on medical record review, observation and resident and staff interview, the facility failed to ensure the heat in a resident's room was working and the temperature was maintained to provide comfort to the resident. This affected one Resident (#51) of 24 residents reviewed for comfortable room temperatures. The facility census was 87.

Inspectors wroteBased on medical record review, staff interviews, and facility policy review the facility failed to notify the ombudsman of discharges from the facility. This affected three Resident's (#24, #62 and #65) of five residents reviewed for discharge notification. The facility census was 87.

Inspectors wroteBased on medial record review, observation, and resident and staff interview, the facility failed to ensure resident medications and mobility statuses were accurately coded on the Minimum Data Set (MDS) assessment. This affected two Resident's (#8 and #68) of 18 residents reviewed for accuracy of assessments. The facility census was 87.

Inspectors wroteBased on medical record review, shower documentation review, and resident and staff interviews, the facility failed to ensure a comprehensive care plan was implemented for resident bathing and skin care needs. This affected two Resident's (#24 and #32) of 18 residents reviewed for care planning. The facility census was 87.

Inspectors wroteBased on medical record review, observation, and resident and staff interview, the facility failed to ensure resident bathing and nutritional care plans were reviewed and revised. This affected two Resident's (# 65 and #78) of 18 residents reviewed for care planning. The facility census was 87.

Inspectors wroteBased on medical record review, shower documentation review, resident and staff interview, and facility policy review the facility failed to ensure residents were provided adequate assistance with activities of daily living (ADL) related to bathing. This affected three Resident's #24, #25 and #78 of three reviewed for ADL's. The facility census was 87.

Inspectors wroteBased on medical record review, observation, and staff interviews, the facility failed to ensure each resident received adequate care for an existing skin condition, and for proper positioning when seated in a wheel chair. This affected two Residents (#29 and #32) of 22 residents reviewed for quality of care. The facility census was 87.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure each resident received timely interventions to address significant weight loss and maintain acceptable parameters of nutritional status. This involved one Resident (#65) of five residents reviewed for nutrition.

Inspectors wroteBased on medical record review, observation, staff interview, review of employee files, review of staff inservice records, review of facility policy, and review of Centers for Disease Control (CDC) guidelines the facility failed to ensure a resident's tracheostomy care was performed in a manner consistent with professional standards and that appropriate signage was posted on the doors of resident's rooms where oxygen was stored or in use in a facility that permits smoking on the premises. This affected one (#7) of one resident the facility identified as requiring tracheostomy care and two (#25 and #233) of eight residents the facility identified as using oxygen. The facility census was 87.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the facility had sufficient staff to perform bathing services. This affected three Resident's (#24, #25 and #78) of 18 residents reviewed for staffing. The facility census was 87.

Inspectors wroteBased on medical record review, observation, staff interview, review of employee files, review of staff inservice records, review of facility policy, and review of Center for Disease Control (CDC) guidelines the facility failed to ensure a resident's tracheostomy care was performed in a manner consistent with professional standards. This affected one (#7) of one resident the facility identified as requiring tracheostomy care. The facility census was 87.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure staff attempted non pharmacological interventions prior to the administration of a pain medication. This affected one Resident (#8) of six reviewed for unnecessary medications. The facility census was 87.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure resident's receiving psychotropic medications had adequate indications for use, and received monitoring for possible side effects. This affected two Residents (#54 and #70) of seven residents reviewed for unnecessary medications. The facility census was 87.

Inspectors wroteBased on observation, staff interview, review of list of residents and review of the facility's medication storage policy, the facility failed to ensure a resident's medications were given and stored in a secured manner. This affected one Resident (#14) who was observed with loose medications in his room. The facility identified two Residents (#12 and #54) as being cognitively impaired and independently mobile residents on the second floor. The facility census was 87.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident's Medication Administration Record (MAR), Treatment Administration Record (TAR) and dialysis documentation was complete and accurate in his medical record. This affected one Resident (#62) of 18 residents reviewed for complete and accurate medical records. The facility census was 87.

Inspectors wroteBased on medical record review, observation, staff interview, review of facility policy, review of Centers for Disease Control guidelines and review of facility census of the second floor the facility failed to ensure a resident's tracheostomy care was performed in a manner to limit the risk of infection. This affected one (#7) of one resident the facility identified as requiring tracheostomy care. The facility also failed to secure and dispose of used disposable razors in a manner that promoted infection control. This had the potential to affect eight Residents (#14, #18, #27, #51, #53, #58, #60 and #284) whom the facility identified as being independent with showers on the second floor. The facility census was 87.

Inspectors wroteBased on medical record review, observation and resident and staff interview, the facility failed to ensure resident's call lights were functioning to allow residents them to call staff for assistance. This affected one (#235) of 24 residents reviewed for call light function. The facility census was 87.

Inspectors wroteBased on review of quality assessment and assurance (QAA) sign in sheets and staff interview, the facility failed to ensure the QAA committee met at least quarterly at the facility and consisted of the required members. This had the potential to affect all 87 residents residing in the facility. The facility census was 87.