Mount Airy, NC
1-star overall rating with 1-star inspections with $145,262 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
542 Allred Mill Road, Mount Airy, NC
(336) 789-5076
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Harborview Health Systems
Operator or chain grouping
Approved since
1981-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
21 facilities
Chain averages 2 overall / 2 health / 3 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.35
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.44
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.19
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
0.79
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.72
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.34
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
12,500
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0.73
Baseline 20.33% · Performance 21.09% · Measure score 0.73 · Achievement 0.73 · Improvement 0
Healthcare-associated infections
2.59
Baseline 6.42% · Performance 7.06% · Measure score 2.59 · Achievement 2.59 · Improvement 0
Total nurse turnover
1.46
Performance 57.69% · Measure score 1.46 · Achievement 1.46 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 2.86 hours · Performance 2.71 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.8% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 128 · Observed rate 9.38% · Lower 95% interval 6.34% |
| Discharge to community | 52.05% |
50.57%
1.5 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 43.93% · Lower 95% interval 45.07% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 11.49% |
95.27%
83.8 pts worse
|
Numerator 10 · Denominator 87 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 87 |
| Discharge self-care score | 40.38% |
53.69%
13.3 pts worse
|
Numerator 21 · Denominator 52 |
| Discharge mobility score | 46.15% |
50.94%
4.8 pts worse
|
Numerator 24 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 2.3% |
2.29%
About the same
|
Numerator 2 · Denominator 87 · Adjusted rate 2.09% |
| Healthcare-associated infections requiring hospitalization | 7.06% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 74 · Observed rate 6.76% · Lower 95% interval 3.89% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 111 |
| Staff flu vaccination coverage | 14.63% |
42%
27.4 pts worse
|
Numerator 18 · Denominator 123 |
| Discharge function score | 46.15% |
56.45%
10.3 pts worse
|
Numerator 24 · Denominator 52 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 7.41% |
25.2%
17.8 pts worse
|
Numerator 4 · Denominator 54 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.0% |
91.5%
13.5 pts worse
|
93.4%
15.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.5% · Q2 79.6% · Q3 86.5% · Q4 75.3% · 4Q avg 78.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.2% |
94.1%
0.1 pts better
|
95.5%
1.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.6%
0.3 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.1% · Q3 3.1% · Q4 4.3% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
4.8%
1.1 pts better
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 8.3% · Q3 1.3% · Q4 1.5% · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
7.2%
3.3 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.4% · Q3 1.2% · Q4 7.8% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.6% |
21.6%
8 pts worse
|
19.6%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 30.8% · Q3 27.4% · Q4 33.3% · 4Q avg 29.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.1% |
15.0%
0.9 pts better
|
16.7%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 14.9% · Q3 14.1% · Q4 12.5% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 41.5% |
21.5%
20 pts worse
|
16.3%
25.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.2% · Q2 50.8% · Q3 40.6% · Q4 35.7% · 4Q avg 41.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 35.2% |
16.8%
18.4 pts worse
|
14.9%
20.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.6% · Q2 35.8% · Q3 34.1% · Q4 30.7% · 4Q avg 35.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.9%
0.2 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 3.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
2.6%
0.1 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 6.1% · Q3 1.0% · Q4 2.2% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.4% |
21.2%
5.2 pts worse
|
19.8%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 28.2% · Q3 26.4% · Q4 28.5% · 4Q avg 26.4% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
6.0%
0.2 pts better
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 8.8% · Q3 4.0% · Q4 2.7% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 39.8% |
79.9%
40.1 pts worse
|
81.7%
41.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 40.8% · Q2 37.4% · Q3 45.2% · Q4 36.4% · 4Q avg 39.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.8% |
13.2%
7.6 pts worse
|
12.0%
8.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 21.6% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.1% · Q3 1.7% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 34.0% |
78.1%
44.1 pts worse
|
79.7%
45.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 34.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.6% |
22.9%
6.7 pts worse
|
23.9%
5.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.6% · Observed 31.1% · Expected 25.0% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-29
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-24
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-28
Inspection history
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-07-14
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-14
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-14
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-14
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-14
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-04-24
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-04-24
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-24
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-24
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-24
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-24
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-04-24
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-04-24
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-24
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-04-24
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-24
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-04-24
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-04-24
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-24
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-24
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-24
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-24
Health
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.
Corrected 2024-04-24
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-04-24
Health
Post nurse staffing information every day.
Corrected 2024-04-24
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-24
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-12-26
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-12-26
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-12-26
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-12-26
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-26
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-12-26
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-12-26
Penalties and ownership
Fine · fine $145,262
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
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