Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Surry Community Health Center By Harborview during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of anxiety and depression was started on Lorazepam without documented consent or prior notification to their representative regarding the risks and benefits. The DON confirmed that the facility's consent process only covered antipsychotic medications, not all psychotropic medications, due to outdated forms.
A resident with anxiety and severely impaired cognition received PRN lorazepam without a required 14-day stop date, resulting in the medication being administered multiple times over two months. The NP and DON acknowledged the oversight, with the NP typically writing such orders for 14 or 30 days but not specifying a stop date in this instance.
Two residents' MDS assessments were inaccurately coded: one resident receiving an antipsychotic was marked as not having received such medication, and another receiving hospice care was not marked as having a life expectancy of less than six months. Errors were acknowledged by the MDS nurse and coordinator, who cited mistakes and unavailable documentation at the time of assessment.
An unsecured, partially full oxygen cylinder was found stored in a resident's room despite no physician order for oxygen therapy. The resident, who had moderately impaired cognition, was unaware of the cylinder's presence or purpose. Nurse aides and the DON confirmed that oxygen cylinders should be stored and secured in the designated storage room, not in resident rooms.
Two residents experienced medication administration errors when a medication aide failed to follow physician orders, resulting in a medication error rate above 5%. One resident received a gastrointestinal medication at the wrong time in relation to meals, and another received an incorrect dosage of an antidepressant. Both errors were attributed to the aide not carefully reading medication cards.
A resident with multiple diagnoses, including chronic pain syndrome and opioid dependence, reported severe pain and anxiety due to not receiving her Methadone as prescribed. Despite the medication being present and documented as administered, the DON did not conduct a thorough investigation. The facility's grievance policy, which mandates prompt investigation and resolution, was not followed. Interviews revealed a lack of proper follow-up and communication, resulting in ongoing distress for the resident.
A resident with a complex medical history, including paralysis, anxiety disorder, and chronic pain syndrome, reported not receiving prescribed Methadone for pain relief during the night shift. Despite physician orders, the resident experienced severe pain, anxiety, nausea, and headaches due to missed doses. Staff, including a Medication Aide, cited reasons such as medication shortages and pharmacy issues. The resident's representative also raised concerns about the facility running out of Methadone. The facility's lack of oversight, documentation discrepancies, and inadequate communication between staff members contributed to the resident not receiving essential pain relief medication as prescribed.
Facility staff failed to disinfect shared glucometers properly, using non-approved disinfectant wipes and not following manufacturer guidelines, leading to potential exposure to bloodborne pathogens among residents.
The facility's QAA committee failed to maintain procedures and monitor interventions, resulting in repeated deficiencies in areas such as abuse and neglect, accuracy of assessments, nutrition and hydration, nurse staffing, pharmacy services, and significant medication errors. These failures included not implementing physician orders, not following abuse policies, and not providing sufficient nursing staff.
The facility failed to ensure proper urinary catheter care for two residents, leading to incidents where catheter bags were not drained in a timely manner. Both residents reported that their catheter bags were not emptied regularly, causing discomfort and potential health risks. Staff interviews and observations confirmed that night shift staff frequently neglected to empty the catheter bags, leaving the task for the morning shift.
The facility failed to update the posted nurse staffing information on each shift for 2 of 5 days during the onsite recertification survey. The ADON and Administrator confirmed that the staffing sheet was only updated every 24 hours, not at each shift change, and the ADON admitted to forgetting to update the information on specific dates.
The facility failed to accurately complete the discharge MDS assessment for a resident. The resident was discharged to the community, but the MDS incorrectly indicated a discharge to a hospital. Interviews revealed the error was due to a mis-click during data entry.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain consent and inform a resident or their representative in advance about the risks and benefits of initiating a psychotropic medication, specifically Lorazepam, for anxiety. The resident in question was admitted with diagnoses including generalized anxiety disorder and depression, and was assessed as severely cognitively impaired with no behavioral symptoms. Despite the initiation of Lorazepam as needed for anxiety, the medical record did not contain documentation that the resident's representative was informed or provided consent prior to starting the medication. During an interview, the DON confirmed that consents were only being obtained for antipsychotic medications, not for all psychotropic medications, due to the limitations of the facility's existing consent forms.
Failure to Include Required Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that an as needed (PRN) psychotropic medication, lorazepam, prescribed for a resident with anxiety, included a required stop date of 14 days as per regulations. The resident, who had a diagnosis of anxiety and severely impaired cognition, was readmitted to the facility and had a physician's order for lorazepam 0.25 mg every 8 hours PRN for anxiety, but the order did not specify a stop date. Review of the resident's medication administration records showed that the medication remained active and was administered multiple times over two months without a stop date. Interviews with the Nurse Practitioner revealed that she typically wrote PRN psychotropic medication orders for 14 days and then evaluated the resident's need, but in this case, she usually wrote the lorazepam order for 30 days due to the resident's behaviors. However, she was unaware of why there was no stop date on the order in the system. The Director of Nursing acknowledged awareness of the requirement for a physician-designated stop date for PRN psychotropic medications and stated that staff were educated on this, but indicated that the lack of a stop date for this resident's lorazepam was an oversight.
Inaccurate MDS Coding for Hospice and Antipsychotic Medication
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for two residents in the areas of hospice care and antipsychotic medication use. For one resident with major depressive disorder and Alzheimer's disease, the medical record showed an active order and administration of quetiapine, an antipsychotic medication. However, the quarterly MDS assessment incorrectly indicated that the resident had not received any antipsychotic medication since the last assessment. The MDS nurse acknowledged marking the wrong answer in the Antipsychotic Medication Review section, stating it was a mistake. For another resident with chronic obstructive pulmonary disease who was certified for hospice care, the quarterly MDS assessment indicated the resident was receiving hospice care but did not mark that the resident had a condition or chronic disease that might result in a life expectancy of less than six months. The MDS Coordinator explained that the hospice recertification was not available at the time of the assessment and was uploaded later, which led to the incorrect coding. The Administrator confirmed that the MDS should have been coded correctly regarding life expectancy and hospice care.
Unsecured Oxygen Cylinder Improperly Stored in Resident Room
Penalty
Summary
A deficiency was identified when an oxygen cylinder was found stored upright and unsecured in a resident's room. The resident, who had moderately impaired cognition, stated she did not know why the oxygen cylinder was in her room and was unaware if she was supposed to be receiving oxygen. Review of her medical records, including the quarterly MDS assessment, care plan, and current physician orders, confirmed that she was not receiving oxygen therapy and had no order for oxygen. The oxygen cylinder was observed to be approximately three-quarters full and remained in the resident's room over multiple observations. Nurse aides responsible for the resident acknowledged that the oxygen cylinder should have been stored in the designated oxygen storage room and secured in a holder to prevent it from falling. They could not recall how long the cylinder had been in the resident's room and stated they had not noticed it previously. The Director of Nursing confirmed that oxygen cylinders should not be stored in residents' rooms and should be secured in the storage room until needed.
Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 31 observed opportunities, resulting in a 6.45% error rate. In the first instance, a resident with gastroesophageal reflux disease was prescribed metoclopramide 5 mg to be administered by mouth before meals. During a medication pass, the medication aide gave the medication while the resident was already eating breakfast, contrary to the physician's order specifying administration before meals. The aide acknowledged not reading the medication card directions closely enough prior to administration. In the second instance, a resident with depression was prescribed escitalopram 20 mg by mouth once daily. During medication administration, the aide prepared and administered only 5 mg of escitalopram instead of the ordered 20 mg. Upon review, the aide realized the error was due to not carefully reading the directions on the medication cards, as there were two cards for different dosages. Both errors were confirmed through staff interviews and direct observation.
Grievance Policy Implementation Failure Leading to Medication Issues
Penalty
Summary
The facility failed to implement its grievance policy and procedures when a resident (Resident #21) reported on 11/30/23 that the facility was running out of her Methadone. The Director of Nursing (DON) did not conduct a thorough investigation despite confirming that the Methadone was present in the medication cart and documented as administered. This lack of investigation led to ongoing issues for Resident #21, who reported experiencing severe pain, anxiety, and withdrawal symptoms due to not receiving her medication as prescribed. The deficiency was identified when Resident #21 filed a grievance, and immediate jeopardy was determined to have begun on 11/30/2023. Resident #21, admitted to the facility with diagnoses including paralysis affecting the lower half of the body, anxiety disorder, neuropathy, major depressive disorder, insomnia, headache, chronic pain syndrome, and opioid dependence, reported significant distress and physical discomfort due to the facility's failure to ensure the availability of her Methadone medication. Despite being cognitively intact as per a quarterly Minimum Data Set (MDS), Resident #21 suffered from severe pain and anxiety when faced with medication supply issues. The facility's grievance policy required the investigation and resolution of grievances promptly, with clear communication of outcomes to residents or their representatives. Interviews with Resident #21, the DON, Resident Representative, Social Worker, and Administrator revealed a lack of proper follow-up and communication regarding Resident #21's grievance. The DON acknowledged not speaking directly with Resident #21 about the issue and failing to follow the grievance process outlined in the facility's policy. The Resident Representative highlighted the emotional toll on Resident #21 and her family due to the ongoing medication supply issues. The facility's failure to address Resident #21's grievance in a timely and thorough manner resulted in a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal.
Pain Management Deficiency Due to Medication Administration Issues
Penalty
Summary
The facility failed to address a resident's pain management needs, specifically for Resident #21, who reported not receiving her Methadone as prescribed for pain relief during the night shift. Resident #21 had a complex medical history including paralysis affecting the lower body, anxiety disorder, neuropathy, neuromuscular dysfunction, major depressive disorder, insomnia, chronic pain syndrome, and opioid dependence. Despite physician orders for Methadone administration at specific times, Resident #21 reported experiencing severe pain, anxiety, nausea, and headaches when her medication was not given. The resident consistently reported this issue to staff, including the Physician Assistant (PA) and nurses, but the problem persisted for an extended period. Multiple staff members, including Medication Aide (MA) #3, were implicated in the deficiency. MA #3 was reported to have frequently not administered Resident #21's Methadone, citing reasons such as the facility running out of medication or pharmacy issues. Resident #21's representative also raised concerns about the facility running out of Methadone and the lack of follow-up on the reported grievances. Despite Resident #21's consistent reports of increased pain and anxiety due to missed medication doses, the facility did not take adequate action to address the issue, leading to prolonged suffering for the resident. The facility's lack of oversight and failure to investigate and address Resident #21's pain management concerns resulted in a deficiency in providing safe and appropriate pain management. The facility's medication administration practices, including documentation discrepancies and staff behavior, contributed to the resident not receiving essential pain relief medication as prescribed. The deficiency was further exacerbated by inadequate communication between staff members, lack of follow-up on reported grievances, and a failure to ensure consistent and appropriate pain management for Resident #21, highlighting systemic issues within the facility's medication management processes.
Failure to Properly Disinfect Shared Glucometers
Penalty
Summary
The facility staff failed to disinfect a shared blood glucose meter (glucometer) after use and before placing it back in the medication cart. This deficiency was observed in three different staff members who did not follow the proper disinfection protocol for the glucometer between residents. Specifically, Nurse #1, Medication Aide #4, and Nurse #7 were involved in this practice, which occurred while there was a resident with known bloodborne pathogens in the facility. The failure to use an EPA-approved disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer posed a high likelihood of exposing residents to bloodborne pathogens. Nurse #1 was observed collecting supplies and using a glucometer to check Resident #60's blood glucose level. After obtaining the results, Nurse #1 placed the glucometer back into the medication cart without disinfecting it. When questioned, Nurse #1 admitted to forgetting to clean the glucometer due to nervousness. Similarly, Nurse #7 used a non-approved disinfectant wipe to clean the glucometer after checking Resident #47's blood glucose level. Nurse #7 was unaware that different disinfectant products had different kill times and believed any disinfectant that claimed to kill germs was sufficient. Medication Aide #4 also used a non-approved disinfectant wipe to clean the glucometer after checking Resident #54's blood glucose level. MA #4 was not aware of the specific cleaning time required to disinfect the glucometer until informed by another nurse. The facility's policies and procedures on cleaning and disinfection of resident-care equipment were not followed, leading to the potential for cross-contamination and exposure to bloodborne pathogens among residents. The facility's staff, including the ADON and DON, acknowledged the failure to use the correct disinfectant product and the need for proper training and adherence to manufacturer guidelines.
Facility's QAA Committee Fails to Maintain Procedures and Monitor Interventions
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions following the recertification survey and complaint investigation. This failure resulted in five deficiencies being recited during the current recertification and complaint investigation. These deficiencies included issues related to abuse and neglect, accuracy of assessments, nutrition and hydration status maintenance, sufficient nurse staffing, pharmacy services and procedures, and significant medication errors. The repeat deficiencies indicated a pattern of the facility's inability to sustain an effective QA program. One of the deficiencies involved the facility's failure to implement a physician order for intravenous fluids for a resident, leading to neglect. Another deficiency was the failure to implement the facility's abuse, neglect, and exploitation policy, which included incidents of involuntary seclusion and unauthorized use of physical restraints by staff. Additionally, the facility failed to accurately complete the discharge Minimum Data Set (MDS) assessment for a resident reviewed for hospitalization. Further deficiencies included the failure to carry out nutritional interventions recommended by the Registered Dietician for a resident with significant weight loss and the failure to provide sufficient nursing staff to honor residents' preferences for showers and incontinence care. The facility also failed to have systems in place for accurately receiving and reconciling controlled medications from the pharmacy, leading to a possible drug diversion. Lastly, the facility failed to prevent significant medication errors, such as not administering medications as ordered by the physician.
Failure to Ensure Proper Urinary Catheter Care
Penalty
Summary
The facility failed to ensure proper urinary catheter care for two residents, leading to incidents where catheter bags were not drained in a timely manner. Resident #4, who has a diagnosis of Neuromuscular Dysfunction of the Bladder, reported that her catheter bag was not emptied regularly, causing it to become so full that it burst open on two occasions. Observations confirmed that her catheter bag was often full, and staff interviews revealed that night shift staff frequently neglected to empty the catheter bags, leaving the task for the morning shift. Despite the facility's policy that only med aides and nurses should perform catheter care, this protocol was not consistently followed, leading to the resident's discomfort and potential health risks. Similarly, Resident #52, also diagnosed with Neuromuscular Dysfunction of the Bladder, experienced issues with his catheter bag not being emptied regularly. The resident reported that his catheter bag was not emptied during the night shift, causing it to become overfilled and leak. Observations and staff interviews corroborated the resident's claims, with staff noting that the night shift often failed to monitor and empty catheter bags, resulting in overfilled bags that had to be addressed by the day shift. The facility's policy requiring only med aides and nurses to handle catheter care was not adhered to, contributing to the resident's distress and potential health complications. Interviews with the Medical Director and Director of Nursing confirmed that improper catheter care could increase the risk of infection and harm to the residents. Both residents' care plans included specific instructions for catheter care, which were not consistently followed by the staff. The facility's failure to ensure that catheter bags were regularly emptied and properly monitored led to significant issues for both residents, highlighting a deficiency in the facility's adherence to its own care protocols.
Failure to Update Nurse Staffing Information on Each Shift
Penalty
Summary
The facility failed to update the posted nurse staffing information on each shift for 2 of 5 days during the onsite recertification survey. On 3/17/24, the daily posted nurse staffing and information sheet was observed to be dated 3/14/24. On 3/19/24, the sheet was not updated at the 7:00 PM shift change and contained the same information as earlier in the day. Interviews with the Assistant Director of Nursing (ADON) and the Administrator revealed that the facility's practice was to update the staffing sheet every 24 hours, not at each shift change, and that the ADON was unaware of the requirement to update the information on each shift. The ADON admitted to forgetting to update the information on 3/16/24 and 3/17/24, and the Unit Manager was unavailable for an interview to explain why the information was not updated on 3/15/24. The Administrator confirmed that the facility operates on 12-hour shifts and that the posted nurse staffing and information sheet was only changed out every 24 hours. The Administrator also stated that the nursing management department was responsible for posting the daily nurse staffing information and that they worked as a team to ensure it was updated daily. However, the posted nurse staffing sheet was only updated throughout the day to reflect actual working hours when there were call outs. The ADON and Unit Manager were identified as the individuals responsible for posting the nurse staffing and information sheet daily.
Inaccurate Discharge MDS Assessment
Penalty
Summary
The facility failed to accurately complete the discharge Minimum Data Set (MDS) assessment for a resident reviewed for hospitalization. The resident was admitted to the facility and later discharged to the community. However, the discharge MDS incorrectly indicated that the resident was discharged to a short-term general hospital. Interviews with the MDS/Resident Assessment Directors revealed that the error was due to a mis-click when entering data into the computer program. The Director of Nursing confirmed that the MDS Nurses were responsible for completing the discharge MDS assessments and acknowledged the error in coding the discharge status.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mount Airy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northern Regional Hospital | 2.4 mi | ★★★★★ | 0 | 0 |
| Central Continuing Care | 3 mi | ★★★★★ | 4 | 0 |
| Heritage Hall - Laurel Meadows | 15.7 mi | ★★★★★ | 0 | 0 |
| Hillsville Health & Rehab Center | 17.5 mi | ★★★★★ | 0 | 0 |
| Chatham Nursing & Rehabilitation | 18.1 mi | ★★★★★ | 0 | 0 |
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