MT AIRY GARDENS REHABILITATION AND NURSING CENTER

This section preserves official CMS inspection text matched to this facility from the current provider page source.

Inspection Report:
2025-02-20
This report is the official CMS Statement of Deficiencies (Form 2567) filed after the most recent health inspection.
Each
14
is a federal standard the facility failed to meet.
Read the full inspection report
Survey: 2025-09-08 | Tag F0812 | Nutrition and Dietary Deficiencies | Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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Survey: 2025-09-08 | Tag F0925 | Environmental Deficiencies | Severity: E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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Survey: 2025-02-20 | Tag F0550 | Resident Rights Deficiencies | Severity: D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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Survey: 2025-02-20 | Tag F0584 | Resident Rights Deficiencies | Severity: D
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.
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Survey: 2025-02-20 | Tag F0641 | Resident Assessment and Care Planning Deficiencies | Severity: D
Ensure each resident receives an accurate assessment.
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Survey: 2025-02-20 | Tag F0646 | Resident Assessment and Care Planning Deficiencies | Severity: D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
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Survey: 2025-02-20 | Tag F0657 | Resident Assessment and Care Planning Deficiencies | Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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Survey: 2025-02-20 | Tag F0684 | Quality of Life and Care Deficiencies | Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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Survey: 2025-02-20 | Tag F0688 | Quality of Life and Care Deficiencies | Severity: D
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.
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Survey: 2025-02-20 | Tag F0692 | Quality of Life and Care Deficiencies | Severity: D
Provide enough food/fluids to maintain a resident's health.
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Survey: 2025-02-20 | Tag F0757 | Pharmacy Service Deficiencies | Severity: D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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Survey: 2025-02-20 | Tag F0761 | Pharmacy Service Deficiencies | Severity: D
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.
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Survey: 2025-02-20 | Tag F0803 | Nutrition and Dietary Deficiencies | Severity: F
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.
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Survey: 2025-02-20 | Tag F0812 | Nutrition and Dietary Deficiencies | Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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Survey: 2025-02-20 | Tag F0849 | Administration Deficiencies | Severity: D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
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Survey: 2025-02-20 | Tag F0914 | Environmental Deficiencies | Severity: D
Provide bedrooms that don't allow residents to see each other when privacy is needed.
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Survey: 2024-08-13 | Tag F0584 | Resident Rights Deficiencies | Severity: E
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.
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Survey: 2024-06-12 | Tag F0760 | Pharmacy Service Deficiencies | Severity: D
Ensure that residents are free from significant medication errors.
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Survey: 2024-05-20 | Tag F0580 | Resident Rights Deficiencies | Severity: D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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Survey: 2024-05-20 | Tag F0657 | Resident Assessment and Care Planning Deficiencies | Severity: B
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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Survey: 2024-05-20 | Tag F0689 | Quality of Life and Care Deficiencies | Severity: J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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Survey: 2024-05-20 | Tag F0921 | Environmental Deficiencies | Severity: E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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Survey: 2021-05-11 | Tag F0558 | Resident Rights Deficiencies | Severity: E
Reasonably accommodate the needs and preferences of each resident.
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Survey: 2021-05-11 | Tag F0578 | Resident Rights Deficiencies | Severity: D
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.
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Survey: 2021-05-11 | Tag F0622 | Resident Rights Deficiencies | Severity: D
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.
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Survey: 2021-05-11 | Tag F0641 | Resident Assessment and Care Planning Deficiencies | Severity: D
Ensure each resident receives an accurate assessment.
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Survey: 2021-05-11 | Tag F0646 | Resident Assessment and Care Planning Deficiencies | Severity: D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
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Survey: 2021-05-11 | Tag F0677 | Quality of Life and Care Deficiencies | Severity: D
Provide care and assistance to perform activities of daily living for any resident who is unable.
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Survey: 2021-05-11 | Tag F0679 | Quality of Life and Care Deficiencies | Severity: E
Provide activities to meet all resident's needs.
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Survey: 2021-05-11 | Tag F0688 | Quality of Life and Care Deficiencies | Severity: D
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.
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Survey: 2021-05-11 | Tag F0689 | Quality of Life and Care Deficiencies | Severity: E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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Survey: 2021-05-11 | Tag F0698 | Quality of Life and Care Deficiencies | Severity: D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
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Survey: 2021-05-11 | Tag F0755 | Pharmacy Service Deficiencies | Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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Survey: 2021-05-11 | Tag F0757 | Pharmacy Service Deficiencies | Severity: D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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Survey: 2021-05-11 | Tag F0758 | Pharmacy Service Deficiencies | Severity: D
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.
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Survey: 2021-05-11 | Tag F0760 | Pharmacy Service Deficiencies | Severity: D
Ensure that residents are free from significant medication errors.
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Survey: 2021-05-11 | Tag F0800 | Nutrition and Dietary Deficiencies | Severity: D
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
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Survey: 2021-05-11 | Tag F0812 | Nutrition and Dietary Deficiencies | Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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Survey: 2021-05-11 | Tag F0842 | Resident Assessment and Care Planning Deficiencies | Severity: D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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Survey: 2021-05-11 | Tag F0880 | Infection Control Deficiencies | Severity: F
Provide and implement an infection prevention and control program.
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Survey: 2021-05-11 | Tag F0919 | Environmental Deficiencies | Severity: D
Make sure that a working call system is available in each resident's bathroom and bathing area.
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Survey: 2024-02-12 | Tag F0921 | Environmental Deficiencies | Severity: E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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Survey: 2023-11-20 | Tag F0624 | Resident Rights Deficiencies | Severity: D
Prepare residents for a safe transfer or discharge from the nursing home.
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Survey: 2023-11-20 | Tag F0689 | Quality of Life and Care Deficiencies | Severity: E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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Survey: 2023-11-20 | Tag F0921 | Environmental Deficiencies | Severity: E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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Survey: 2023-06-07 | Tag F0584 | Resident Rights Deficiencies | Severity: E
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.
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Survey: 2023-06-07 | Tag F0657 | Resident Assessment and Care Planning Deficiencies | Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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Survey: 2023-06-07 | Tag F0684 | Quality of Life and Care Deficiencies | Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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Survey: 2023-06-07 | Tag F0755 | Pharmacy Service Deficiencies | Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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Survey: 2023-06-07 | Tag F0761 | Pharmacy Service Deficiencies | Severity: D
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.
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Survey: 2023-06-07 | Tag F0804 | Nutrition and Dietary Deficiencies | Severity: D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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Survey: 2023-04-28 | Tag F0690 | Quality of Life and Care Deficiencies | Severity: D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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Survey: 2023-03-03 | Tag F0812 | Nutrition and Dietary Deficiencies | Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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Survey: 2019-03-07 | Tag F0550 | Resident Rights Deficiencies | Severity: D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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Survey: 2019-03-07 | Tag F0569 | Resident Rights Deficiencies | Severity: D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
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Survey: 2019-03-07 | Tag F0580 | Resident Rights Deficiencies | Severity: D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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Survey: 2019-03-07 | Tag F0584 | Resident Rights Deficiencies | Severity: D
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.
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Survey: 2019-03-07 | Tag F0623 | Resident Rights Deficiencies | Severity: D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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Survey: 2019-03-07 | Tag F0641 | Resident Assessment and Care Planning Deficiencies | Severity: D
Ensure each resident receives an accurate assessment.
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Survey: 2019-03-07 | Tag F0656 | Resident Assessment and Care Planning Deficiencies | Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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Survey: 2019-03-07 | Tag F0657 | Resident Assessment and Care Planning Deficiencies | Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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Survey: 2019-03-07 | Tag F0677 | Quality of Life and Care Deficiencies | Severity: D
Provide care and assistance to perform activities of daily living for any resident who is unable.
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Survey: 2019-03-07 | Tag F0684 | Quality of Life and Care Deficiencies | Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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Survey: 2019-03-07 | Tag F0692 | Quality of Life and Care Deficiencies | Severity: D
Provide enough food/fluids to maintain a resident's health.
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Survey: 2019-03-07 | Tag F0695 | Quality of Life and Care Deficiencies | Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
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Survey: 2019-03-07 | Tag F0725 | Nursing and Physician Services Deficiencies | Severity: D
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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Survey: 2019-03-07 | Tag F0726 | Nursing and Physician Services Deficiencies | Severity: D
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.
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Survey: 2019-03-07 | Tag F0730 | Nursing and Physician Services Deficiencies | Severity: F
Observe each nurse aide's job performance and give regular training.
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Survey: 2019-03-07 | Tag F0756 | Pharmacy Service Deficiencies | Severity: E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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Survey: 2019-03-07 | Tag F0757 | Pharmacy Service Deficiencies | Severity: D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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Survey: 2019-03-07 | Tag F0758 | Pharmacy Service Deficiencies | Severity: D
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.
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Survey: 2019-03-07 | Tag F0761 | Pharmacy Service Deficiencies | Severity: D
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.
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Survey: 2019-03-07 | Tag F0842 | Resident Assessment and Care Planning Deficiencies | Severity: D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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Survey: 2019-03-07 | Tag F0868 | Administration Deficiencies | Severity: C
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
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Survey: 2019-03-07 | Tag F0880 | Infection Control Deficiencies | Severity: D
Provide and implement an infection prevention and control program.
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Survey: 2019-03-07 | Tag F0919 | Environmental Deficiencies | Severity: D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Source: U.S. Centers for Medicare & Medicaid Services. Data reflects the most recent available inspection.