Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Mount Airy Nursing And Rehab Center during CMS and state inspections, most recent first.
A facility failed to protect residents from abuse and intimidation. One resident with a history of sexually inappropriate and aggressive behaviors was allowed to remain in contact with others despite repeated incidents of inappropriate touching, threats, and verbal altercations, and another resident reported being touched in private areas. The facility also did not fully investigate an allegation that an aide had been taught to hit a resident or suspend the staff involved pending the investigation. In a separate incident, a GNA threatened a resident during med pass, grabbed the resident’s hand, and moved a fist toward the resident’s face, leaving the resident scared and feeling unsafe.
Failure to Report Substantiated Abuse and Incomplete Abuse Investigations: A resident reported that a GNA threatened and physically intimidated the resident during medication administration, and the facility later substantiated the abuse based on staff statements, but leadership did not report the finding to the nurse aide registry and did not know the reporting process for a credentialed aide. In separate abuse investigations, the facility did not interview all relevant staff and left multiple resident assessment forms blank, including an allegation that a resident was touched in private areas and another report that a GNA said she had been taught to hit a resident.
The facility failed to include adverse event monitoring of alleged physical and sexual abuse in its QAPI activities. Surveyors reviewed 2 FRIs involving injuries of unknown origin and 4 FRIs involving alleged abuse, and the DON stated these incidents had not been reviewed or tracked through the QAPI process, despite facility policy requiring abuse, neglect, and misappropriation investigations to be reviewed by QAPI.
Delayed Reporting of Injury of Unknown Origin: Staff observed new bruising and redness around a resident’s eye, but documentation showed conflicting accounts of when the injury was first seen and when management was notified. Multiple GNAs reported the injury, one RN said nothing had been reported to her, and another RN later observed bluish discoloration and notified the Manager on Call. The facility’s report to OHCQ listed a later discovery time than what staff statements reflected, and the NHA confirmed staff did not follow the facility’s reporting protocol.
A resident's legal representative, designated as healthcare surrogate, was denied timely access to the resident's medical records after submitting two written requests. The facility referred the requests to corporate staff, who declined to release the records.
Failure to provide and document resident activities. Five residents reviewed for Activities had blank one-to-one activity logs with no entries and no documentation of refusal or unavailability. The ADON/Activities Director stated the documentation was inconsistent and confirmed there was no evidence that any activities were provided to those residents.
Unsecured medication and treatment carts were observed unattended in multiple areas, with drawers open and supplies and resident medication blister packs visible and accessible, including a cart near a resident room and another near the nursing station with a resident nearby. In addition, an inhaler for a resident was found past the manufacturer’s discard timeframe, and the eMAR showed the AM dose was documented as given even though the LPN later stated it should have been discarded and had not been administered after he realized it was expired. The DON confirmed the documentation and stated the facility’s practice was to discard medications after 30 days.
Inaccurate Dental Assessment: A resident's admission oral status assessment documented no oral concerns, but key questions about absent or broken teeth were left blank. During observation, no teeth were seen, and the resident stated they had no teeth and had dentures but did not know where they were. The DON later confirmed the resident had no teeth and said the nursing documentation should have reflected that.
Medication Error Rate Exceeded 5 Percent During Observation: During a med pass observation, 2 LPNs made 2 medication errors out of 29 opportunities, resulting in a 7% error rate. Two residents received Geri-Kot instead of the ordered Senna-S, even though Senna-plus was available in the med carts and the LPNs confirmed the mismatch.
A dinner observation found that meal trays were missing items listed on residents’ meal tickets, including buttered dinner rolls and yogurt. Staff confirmed the omissions for three residents, and a long-term resident also reported that meal portions were small and sometimes not enough to eat.
Infection control lapses were observed in the laundry room and dining room. A laundry aide handled soiled laundry without PPE, despite knowing PPE was required, and a GNA fed two residents at the same time without performing hand hygiene between residents; the DON observed the feeding practice without comment.
A resident's call light was observed hooked over a wall light behind the bed and positioned about 5 feet off the floor, making it out of reach and not accessible. A later observation showed the call light in the same location, and the ICN confirmed it was not within the resident's reach.
Failure to Protect Residents from Abuse and Intimidation
Penalty
Summary
The facility failed to ensure residents remained free from sexual, physical, and verbal abuse, as well as intimidation by staff and another resident. One resident with a documented pattern of sexually inappropriate, aggressive, and disruptive behaviors toward residents and staff was involved in multiple prior incidents, including threatening another resident, verbal altercations, inappropriate touching of another resident in the hallway, and attempts to touch staff. Despite documentation that the resident had required 1:1 supervision because of these behaviors, the supervision was discontinued even though the record continued to show ongoing inappropriate conduct. The day after the supervision was stopped, another resident reported that the resident had touched their private areas, and the resident later stated that the touching occurred while the resident was seated on a walker. The facility also failed to adequately investigate an allegation involving a resident and staff members. A GNA reported overhearing another GNA say that an aide had been taught to hit a resident and had done so. The investigation file did not include statements from the staff member identified as the trainer, did not show additional staff statements, and did not show that the allegation was comprehensively investigated as abuse. The file also did not show that the staff members alleged to be involved were suspended pending the investigation, even though facility policy stated that an employee alleged to be involved in abuse would be immediately removed from resident care and not left alone until the investigation was complete. The facility further failed to protect another resident from verbal, mental, and physical intimidation by a GNA during medication administration. That resident, who had diagnoses including CHF, type 2 DM, CKD, generalized anxiety disorder, moderate intellectual disability, and peripheral vascular disease, reported that the GNA threatened to break their fingers if they did not take medication. The resident stated the GNA grabbed their hand, made a fist, and moved it toward their face, and also described prior threatening statements by the same staff member. The facility substantiated the allegation based on staff statements and the resident’s account, and the resident stated they felt scared and did not feel safe when cared for by that staff member.
Failure to Report Substantiated Abuse and Incomplete Abuse Investigations
Penalty
Summary
The facility failed to complete 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. One resident with diagnoses including congestive heart failure, type 2 diabetes mellitus, chronic kidney disease, generalized anxiety disorder, moderate intellectual disability, and peripheral vascular disease reported that a GNA threatened to break the resident’s fingers if the resident did not take medication. The resident stated the GNA also grabbed the resident’s hand, made a fist, and drew it toward the resident’s face, and that the GNA had spoken to the resident in that manner many times before. The facility substantiated the allegation based on staff statements describing the GNA as loud, rude, disrespectful, and aggressive toward residents and staff, and the GNA was terminated. Although the facility substantiated the abuse involving the GNA, leadership did not initiate reporting to the Maryland Nurse Aide Registry and did not know the process for reporting substantiated abuse findings involving a credentialed nursing assistant. The DON stated she was unaware of the registry and the reporting process, and the NHA confirmed the failure to report was a systemic and operational oversight. The facility had notified OHCQ of the substantiated allegation, but the substantiated finding had not been reported to the registry at the time of survey review. The facility also failed to thoroughly investigate an allegation involving a resident who overheard a GNA say that while in training she was taught to hit another resident and witnessed another aide hit that resident. The investigation file contained statements from the reporting GNA, the accused GNA, and a nurse, but did not show that additional staff interviews were conducted, including an interview with the staff member identified as the trainer and alleged perpetrator. Several resident assessment forms in the packet were left completely blank and signed by a nurse. In another abuse investigation involving a resident who reported that another resident touched her in her private areas, multiple resident assessment forms were left blank by the DON and a nurse. The DON stated blank assessments provided no information and acknowledged that incomplete assessments may have caused important evidence to be missed, while the NHA stated she should have identified the incomplete assessments as well.
Failure to Include Abuse and Injury Incidents in QAPI Review
Penalty
Summary
The facility failed to include adverse event monitoring of alleged physical and sexual abuse in its Quality Assurance and Performance Improvement (QAPI) activities. Based on record review and interviews, this was identified for 2 of 2 facility reported incidents involving injuries of unknown origin and 4 of 4 facility reported incidents involving allegations of abuse. The incidents reviewed included FRI #2670676 and #2686939 for injuries of unknown origin, and FRI #2707002, #2787931, #2987931, and #3012852 for alleged abuse. According to the facility policy, all investigations involving abuse, neglect, and misappropriation are to be reviewed by the QAPI committee. During the survey, the Nursing Home Administrator stated that resident safety is prioritized when determining areas of focus for QAPI. When asked whether any of the alleged abuse incidents or injuries of unknown origin had been reviewed or tracked through the facility's QAPI process, she stated that they had not.
Delayed Reporting of Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown origin for one resident after staff observed new bruising and discoloration to the resident’s left eye. Multiple staff members documented seeing the injury on the evening and night shift, including a GNA who noted a new bruise to the resident’s eye, another GNA who observed bruising to the left eyelid, and a third GNA who saw redness on and around the left eye. One RN documented that nothing had been reported to her regarding the discoloration, while another RN stated she observed bluish discoloration to the left upper eyelid during medication administration and notified the Manager on Call. The facility’s internal investigation showed that staff statements conflicted about when the injury was first observed and when management was notified. The Unit Manager stated he did not receive any calls from staff over the weekend regarding bruising or discoloration to the resident’s left upper eyelid, and there was no documentation identifying when management was initially notified after staff first observed the injury. The facility’s initial report to OHCQ listed the injury as discovered at 7:03 AM, but an RN documented discovery at approximately 6:00 AM, and multiple staff reported seeing and reporting the injury on the prior day. The NHA stated staff were expected to immediately report incidents to the Unit Manager, even when not physically present, and confirmed staff failed to follow facility protocol related to reporting the injury of unknown origin.
Failure to Provide Resident Records to Legal Representative
Penalty
Summary
The facility failed to provide a resident's legal representative with a copy of the resident's medical record in a timely manner, despite two written requests submitted during the resident's stay. The resident, who had diagnoses including cerebrovascular accident, Parkinsonism, and vascular dementia, was deemed incompetent by two physicians prior to admission, and the daughter was listed as the healthcare surrogate. The representative submitted authorization forms for the release of the medical records on two occasions, but was informed that the requests would be referred to the facility's legal team. According to the facility administrator, the requests were sent to corporate staff, who decided not to release the records to the responsible party.
Failure to Provide and Document Resident Activities
Penalty
Summary
The facility failed to provide activities for five residents reviewed for Activities during the recertification survey. During an interview, the Activities Director stated that the activity program offered mental stimulation, creative expression, and physical activity in group and individual settings, and that residents who did not like group activities or who had dementia would be offered different activities such as music, talking, and tactile activities. However, a review of the activities tracking binder showed blank pages for five residents, with each page indicating the resident should have weekly one-to-one activity. There were no activities documented on any of the pages and no documentation of refusal or unavailability. When the blank forms were reviewed with the Activities Director and the NHA, the Activities Director stated that documentation had been inconsistent but confirmed there was no evidence that any activities were provided to those residents.
Unsecured medication carts and expired inhaler storage
Penalty
Summary
Medication and treatment carts were found unsecured and unattended during multiple observations in the A and B buildings. In A building, a treatment cart was observed unlocked and unattended in front of the nurses’ station during meal time and tray distribution, with drawers open and supplies visible and accessible, including shears, over-the-counter topical medications, and adhesives. Later the same day, a medication cart near a resident room was also observed unlocked and unattended, with resident medication blister packages exposed while a resident was walking in the hallway nearby. In B building, one of the treatment carts near the nursing station was observed unlocked and accessible with a resident nearby in the hallway. Staff intervened after the observations, and the Administrator and DON confirmed it was their expectation that medication and treatment carts remain locked when unattended. A medication storage issue was also identified with a resident’s inhaler in A building. An inhaler for a resident was observed with an open date that exceeded the manufacturer’s instruction to discard it one month after opening. Review of the resident’s eMAR showed the inhaler was scheduled twice daily, and the AM dose had been documented as administered by an LPN even though the LPN later stated the inhaler should have been discarded already and that he had not administered the dose after realizing it was expired. The DON confirmed the documentation showed the AM dose as given and stated the facility’s practice was to discard medications after 30 days, meaning the inhaler should have been discarded on the earlier date. The facility policy stated medications and biologicals were to be stored safely, securely, and properly according to manufacturer or supplier recommendations.
Inaccurate Dental Assessment
Penalty
Summary
The facility failed to accurately assess a resident's dental status. In the nursing admission assessment for Resident #69, the oral status section stated there were no oral concerns, but the questions indicating whether the resident had no teeth or had broken or missing teeth were left unanswered. During an observation and interview in the resident's room, no teeth were seen in the resident's mouth, and the resident stated they had no teeth and had dentures but did not know where the dentures were. When asked whether they were able to eat the food provided, the resident did not give a specific answer. On a later joint observation with the DON, the DON looked in the resident's mouth and confirmed the resident did not have any teeth and stated the nursing documentation should have described that. The NHA later acknowledged the deficiency.
Medication Error Rate Exceeded 5 Percent During Observation
Penalty
Summary
The facility failed to ensure medication error rates remained below 5 percent during a medication administration observation. During the task started on 8/28/25 at 8:04 AM, surveyors observed 29 medication administration opportunities between 2 LPNs, and 2 errors were identified, resulting in a 7% medication error rate. On 8/28/25, one LPN administered Geri-Kot (sennosides 8.6 mg) to Resident #51 even though the order was for Senna-S (sennosides-docusate sodium 8.6-50 mg). The LPN later confirmed the order was for Senna-S and that Geri-Kot did not contain the docusate sodium component; Senna-plus, which matched the ordered medication, was available in the medication cart. The same issue was observed with another LPN administering Geri-Kot to Resident #44 when the order was also for Senna-S, and the LPN likewise confirmed that Senna-plus was available but was not given. The DON was informed that both administrations were counted as errors out of 29 observed opportunities.
Incomplete Meal Trays Served to Residents
Penalty
Summary
The facility kitchen failed to provide residents with the meals indicated on their meal tickets during a dinner dining observation. Resident #5’s meal ticket showed a buttered dinner roll, but the tray served did not include one, and GNA Staff #10 confirmed the omission. Resident #65’s meal ticket also showed a buttered dinner roll, but the tray served did not contain one, and GNA Staff #11 confirmed it was missing. Resident #33’s meal ticket showed yogurt, but the dinner tray did not contain yogurt, and GNA Staff #10 confirmed that omission. During the observation, a long-term resident also reported that meal portions were small and that the food served was sometimes not enough to eat.
Infection Control Lapses During Laundry Handling and Feeding Assistance
Penalty
Summary
Failure to provide and implement an infection prevention and control program was identified in two separate observations. In one observation of the soiled laundry room in Building A, a laundry aide was seen standing in front of the washing machine with the door open and was not wearing any PPE while handling dirty laundry. The aide stated that her normal process was to wear a gown and gloves and pointed to where the PPE was stored, but said she was busy and did not put it on. She also stated that she knew she was supposed to wear it and reported having worked at the facility for 38 years. In a separate dining observation in Building A, a GNA was observed sitting between two residents and assisting both of them with eating at the same time. The GNA did not perform hand hygiene between assisting the two residents. The DON observed the GNA feeding both residents without proper hand hygiene and did not comment at the time of the observation. The Administrator later acknowledged concerns regarding infection control and stated the issue had been addressed with the GNA.
Call Light Not Within Resident Reach
Penalty
Summary
The facility failed to ensure that a resident's call system device was within reach and available in the resident's room. During an observation in Resident #60's room, the call light was found hooked over the wall light behind the bed, approximately 5 feet off the floor, making it inaccessible to the resident. A later observation showed the call light in the same out-of-reach location. The observation was confirmed by the infection control nurse, who acknowledged the call light was not accessible to the resident.
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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) |
|---|---|---|---|---|
| Lorien Health Systems Mt Airy | 1.2 mi | ★★★★★ | 29 | 0 |
| Copper Ridge Nursing And Assisted Living Center | 8.8 mi | ★★★★★ | 6 | 1 |
| Willowbrooke Court Skilled Care Center Fairhaven | 9 mi | ★★★★★ | 5 | 0 |
| Autumn Lake Healthcare At Birch Manor | 9 mi | ★★★★★ | 1 | 0 |
| Autumn Lake Healthcare At Ballenger Creek | 11.3 mi | ★★★★★ | 4 | 0 |
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