Deficiency Records for Mt Airy Gardens Rehabilitation and Nursing Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Mt Airy Gardens Rehabilitation and Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-11-20 | 2023-12-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-20 | 2023-12-01 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-11-20 | 2023-12-01 | Y |
| 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. | Health | 2023-06-07 | 2023-06-15 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-07 | 2023-06-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-07 | 2023-06-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-07 | 2023-06-15 | Y |
| 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. | Health | 2023-06-07 | 2023-06-15 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-07 | 2023-06-15 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-28 | 2023-05-06 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-03 | 2023-03-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-06 | 2023-03-20 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-26 | 2023-03-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-26 | 2023-03-20 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-03 | 2023-03-20 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-03 | 2023-03-20 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-01-03 | 2023-03-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-26 | 2022-12-02 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-26 | 2022-12-02 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-08 | 2022-12-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-08 | 2022-12-02 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-08 | 2022-12-02 | Y |
| 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. | Health | 2022-09-08 | 2022-12-02 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-20 | 2022-12-02 | Y |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-09-20 | 2022-12-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-18 | 2022-02-25 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-12-20 | 2022-01-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-20 | 2022-01-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-02 | 2021-09-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-02 | 2021-09-23 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-09-02 | 2021-09-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-09-02 | 2021-09-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-17 | 2021-09-23 | Y |
| 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. | Health | 2021-08-17 | 2021-09-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-17 | 2021-09-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-17 | 2021-09-23 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-08-17 | 2021-09-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-17 | 2021-09-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-11 | 2021-06-08 | N |
| 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. | Health | 2021-05-11 | 2021-06-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-11 | 2021-06-08 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2021-05-11 | 2021-06-08 | N |
| Provide activities to meet all resident's needs. | Health | 2021-05-11 | 2021-06-08 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-05-11 | 2021-06-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-05-11 | 2021-06-08 | N |
| 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. | Health | 2021-05-11 | 2021-06-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-11 | 2021-06-08 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-05-11 | 2021-06-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-11 | 2021-06-08 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-05-11 | 2021-06-08 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-05-11 | 2021-06-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-11 | 2021-06-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-11 | 2021-06-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-11 | 2021-06-08 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-11 | 2021-06-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-11 | 2021-06-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-11 | 2021-06-08 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2021-05-11 | 2021-06-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-11 | 2021-06-08 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-05-11 | 2021-06-08 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-05-11 | 2021-06-08 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-05-11 | 2021-06-08 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-05-11 | 2021-06-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-11 | 2021-06-08 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-05-11 | 2021-06-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-11 | 2021-06-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-11 | 2021-06-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-05-11 | 2021-06-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-11 | 2021-06-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-11 | 2021-06-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-11 | 2021-06-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-11 | 2021-06-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-07 | 2019-04-05 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-03-07 | 2019-04-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-03-07 | 2019-04-05 | N |
| 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. | Health | 2019-03-07 | 2019-04-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-07 | 2019-04-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-07 | 2019-04-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-07 | 2019-04-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-03-07 | 2019-04-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-07 | 2019-04-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-07 | 2019-04-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-03-07 | 2019-04-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-07 | 2019-04-05 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-03-07 | 2019-04-05 | N |
| 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. | Health | 2019-03-07 | 2019-04-05 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-03-07 | 2019-04-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-03-07 | 2019-04-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-07 | 2019-04-05 | N |
| 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. | Health | 2019-03-07 | 2019-04-05 | N |
| 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. | Health | 2019-03-07 | 2019-04-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-07 | 2019-04-05 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-03-07 | 2019-04-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-07 | 2019-04-05 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-03-07 | 2019-04-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-03-11 | 2019-04-05 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-03-11 | 2019-04-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-03-11 | 2019-04-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-03-11 | 2019-04-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-03-11 | 2019-04-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-11 | 2019-04-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-03-11 | 2019-04-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-03-11 | 2019-04-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-11 | 2019-04-05 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-03-11 | 2019-04-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-11 | 2019-04-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-01-25 | 2018-02-23 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-01-25 | 2018-02-23 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-01-25 | 2018-02-23 | N |
| 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. | Health | 2018-01-25 | 2018-02-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-01-25 | 2018-02-23 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-01-25 | 2018-02-23 | N |
| Provide activities to meet all resident's needs. | Health | 2018-01-25 | 2018-02-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-01-25 | 2018-02-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-01-25 | 2018-02-23 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-01-25 | 2018-02-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-01-25 | 2018-02-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-25 | 2018-02-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-01-25 | 2018-02-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-01-24 | 2018-02-23 | N |
