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Mountain City Rehab Center

48 Tarn Terrace, Frostburg, MD 21532 · Allegany County · (301) 689-1391

88 certified beds, about 84 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1995

CMS abuse icon: cited for abuse in a recent inspection Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
3 of 5
Quality measures
3 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 215277 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on March 6, 2026, inspectors cited 13 health deficiencies (the Maryland average is 17, the national average 9.2).

Of 65 health citations since September 2019, 3 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).

CMS lists 3 fines totaling $48,227 in the last three years; the largest was $16,562, and the latest is dated November 7, 2025.

Nurses and nurse aides worked 3.50 hours per resident per day, against 3.87 across Maryland and 3.86 nationally. Registered nurses accounted for 0.75 of those hours.

48.4% of nursing staff left within the year CMS measured (Maryland average 40.2%).

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 65 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
47D
13E
1F
Potential for minimal harm
0A
0B
1C
March 6, 2026Standard inspection, Complaint inspection · 13 citations
  1. E
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    F628 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 30, 2026
    Inspectors wroteBased on record review and interview it was determined that the facility failed to provide the required information to the resident and their representatives at the time of discharge to the hospital; and failed to ensure required documents were sent with the resident to the hospital at the time of transfer. This was found to be evident for two (Resident #6 and #9) out of three residents reviewed for hospitalization.
  2. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2026
    Inspectors wroteBased on observations and interviews, it was determined that the facility failed to treat residents with respect and dignity, as evidenced by failing to knock and request permission before entering residents' rooms. This was evident for 2 (Resident #79, #72) of 2 residents reviewed for dignity.
  3. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2026
    Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility failed to provide reasonable accommodations to maintain residents' independence by failing to ensure access to remote bed controls that worked to adjust their bed settings independently. This was evident in 1 of 2 room observations.
  4. 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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2026
    Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure a clean, comfortable, and home-like environment for residents. This was evident in 1 of 2 rooms identified with environmental concerns during the survey.
  5. D
    Protect each resident from the wrongful use of the resident's belongings or money.
    F602 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 30, 2026
    Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to monitor and prevent the misappropriation of resident property. This was evident for 1 (Resident #76) of 4 residents reviewed for abuse during the recertification survey.
  6. D
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    F640 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2026
    Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure the completion of a death in facility tracking record for a resident who expired. This was found to be evident for one (Resident #44) out of one resident reviewed for the Resident Assessment task.
  7. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2026
    Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to ensure that a resident participated in the care planning process and that interdisciplinary team (IDT) care conference meetings were conducted following completion of MDS assessments. This was evident in one (Resident#12) of three residents reviewed for care planning during the survey.
  8. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2026
    Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure a resident's medication was obtained in a timely manner and that it was administered as ordered. This was found to be evident for one (Resident #5) out of one resident reviewed for dialysis.
  9. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2026
    Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to ensure necessary equipment for pressure ulcer prevention was properly functioning and monitored. This was evident for 1 (Resident #8) of 1 residents reviewed for pressure ulcers.
  10. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2026
    Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility failed to maintain respiratory care equipment for residents who required continuous oxygen via nasal cannula. This was evident in 1 (Resident #72) of 3 residents reviewed for respiratory care.
  11. D
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2026
    Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure staff completed physical assessment of resident after they returned from dialysis treatment. This was found to be evident for one (Resident #5) out of one resident reviewed for dialysis.
  12. 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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2026
    Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to ensure medications were labeled and discarded when expired. This was evident in 2 of 3 medication carts observed during medication storage and labeling inspection.
  13. D
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    F887 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2026
    Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to offer and administer covid-19 immunization to residents. This was evident for 2 (Resident #11 and #59) of 5 residents reviewed for immunizations.
November 7, 2025Complaint inspection · 9 citations
  1. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 7, 2026
    Inspectors wroteBased on facility policy review, record review, facility document review, interview, and observation, the facility failed to ensure the residents' environment remained as free of accident hazards as possible, which affected 4 (Resident #8, #7, #12, and #18) of 9 residents reviewed for accidents or falls during the complaint survey. Specifically, Resident #8 was improperly transferred by one staff when they required two staff to safely transfer causing actual harm.
  2. E
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 7, 2026
    Inspectors wroteBased on facility policy review, record review, facility document review, and interview, the facility failed to report allegations of abuse, including injury of unknown origin, to the state survey agency within the required timeframe, which affected 6 (Residents #14, #15, #4, #7, #19, and #10) of 12 residents reviewed for abuse or resident-to-resident altercations.
  3. E
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 7, 2026
    Inspectors wroteBased on facility policy review, record review, facility document review, and interview, the facility failed to conduct a thorough investigation or maintain evidence of a thorough investigation. The facility also failed to protect residents from potential further abuse by allowing an alleged abuser to remain in the building. The deficiencies affected 6 (Residents #14, #15, #16, #4, #7, and #19) of 12 residents reviewed for abuse or resident-to-resident altercations during the complaint survey.
  4. E
    Have a plan that describes the process for conducting QAPI and QAA activities.
    F865 · Administration · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 7, 2026
    Inspectors wroteBased on facility document review and interview, the facility failed to ensure their Quality Assurance Performance Improvement (QAPI) program effectively implemented a plan to address quality deficiencies identified related to falls. This deficient practice affected 3 (Residents #7, 12, and #18) of 9 sampled residents reviewed for accidents during the complaint survey.
  5. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 7, 2026
    Inspectors wroteBased on facility policy review, record review, and interview, the facility failed to ensure staff communicated all pertinent information to a physician, which affected 1 (Resident #4) of 4 residents reviewed for abuse.
  6. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 7, 2026
    Inspectors wroteBased on facility policy review, record review, facility document review, and interview, the facility failed to protect the resident's right to be free from physical and verbal abuse by a staff member for 1 (Resident #4) of 4 residents sampled for abuse during the complaint survey.
  7. D
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 7, 2026
    Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to implement their policies regarding investigating, documenting, and reporting an incident of resident-to-resident abuse, for one (Resident #14) of 12 residents reviewed for abuse or resident-to-resident altercations during the complaint survey.
  8. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 7, 2026
    Inspectors wroteBased on interview, record review, facility policy review, and the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.19.1, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded for 1 (Resident #4) of 19 residents reviewed for accuracy of MDS assessments during the complaint survey.
  9. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 7, 2026
    Inspectors wroteBased on facility policy review, record review, and interview, the facility failed to ensure staff accurately assessed a resident following a change in condition and failed to respond appropriately during the change of condition, which affected 1 (Resident #4) of 4 residents reviewed for abuse during the complaint survey.
November 26, 2024Standard inspection, Complaint inspection · 37 citations
  1. J
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on review of facility reported incident investigation documents and medical records, interviews and observations it was determined that the facility failed to provide adequate supervision to prevent a vulnerable resident from exiting the facility unattended by staff. This was found to be evident for 1 (Resident #234) out of 3 residents reviewed in relation to facility self reports of elopement during the survey.
  2. G
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 31, 2025
    Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to provide care to prevent the development of pressure ulcers. This was found to be evident for one(Resident #34) out of four residents reviewed for pressure ulcers during the survey. This deficient practice resulted in actual harm to Resident #34.
  3. F
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    F851 · Administration · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on record review and interview it was determined that the facility failed to submit their Payroll Based Journal (PBJ) information to Medicare. This was evident in the off-site preparation portion and during the on-site recertification survey.
  4. E
    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.
    F578 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wrote2) On 11/12/24 review of Resident #31's medical record revealed a Decision Making Capacity form, signed by the physician on 4/10/24, that indicated the resident was able to make health care decisions. Review of the Social Service 72 Hour Meeting Form, signed by the Social Worker (SW Staff #10), revealed the question: Does the resident have an Advance Directive? was marked as No. Further review of the medical record failed to reveal documentation to indicate there was follow up with the resident about initiating an Advance Directive. On 11/13/24 at 3:42 PM the SW #10 indicated if the answer to the Advance Directive question is No she does not follow up. On 11/14/24 review of the admission packet used by the facility revealed a blank Advance Directive form. [...]
  5. E
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure a primary care provider was notified of an abnormal lab result. This was found to be evident for 1 (Resident #53) out of 5 resident reviewed for unnecessary medications.
  6. E
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on record review and interview it was determined that the facility failed to 1) report allegations of abuse, and 2) timely report allegations of abuse. This was evident for two residents (Resident #1 and #12) identified during a review of an employee file and 4 residents (Residents #55, #72, #245, and #51) reviewed in relationship to 25 facility reported incidents reviewed during the survey.
  7. E
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented. This was evident for 1 (Resident #16) of 3 residents reviewed for vision/hearing; and 1 (Resident #57) of 4 residents reviewed for dementia care.
  8. E
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on medical record review staff interview, it was determined the facility failed to provide a resident and/or a resident's representative with a summary of the baseline care plan. This was evident for 3 Residents (#82, #237, #255) of 50 residents reviewed during the survey.
  9. E
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on interviews and medical record review, it was determined that the facility failed to invite alert and oriented residents to their care plan meetings. This was evident for 2 (#52, #136) of 2 residents reviewed for care planning. {or include the additional 2 for 4 out of 50}
  10. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure staff reviewed/acknowledged specialists recommendations; failure to ensure assessment were completed accurately and failed to follow physician orders. This was found to be evident for five (Resident #31, #256, #16, #11 and #83) out of 50 residents reviewed during the survey.
  11. E
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) January 31, 2025
    Inspectors wroteBased on observations and interviews, it was determined that the facility failed to store medications in accordance with professional standards by failing to discard expired medications; failing to ensure medicated creams were kept in the locked medication carts or storage rooms; and failure to ensure discontinued controlled medications were removed and discarded. This was evident in 1 of 3 medication carts observed during medication storage and labeling inspection; and 3 (Resident #30, #44 and #66) of 50 residents reviewed during the survey.
  12. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on interviews, pertinent document reviews and observations it was determined that the facility failed to respond in a timely manner to a resident request for assistance. This was evident for 2 (Resident #24, #18) observed during a random observation on Nursing unit 1.
  13. D
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    F582 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on review of pertinent documentation and interviews it was determined that the facility failed to ensure resident's were provided advance notification of the date Medicare would not cover their skilled services. This was found to be evident for 1(Resident #14) out of 3 residents reviewed for beneficiary protection notification review.
  14. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on medical record and facility investigation documentation and interviews it was determined that the facility failed to protect the residents from verbal abuse and misappropriation of narcotics. This was found to be evident for two (Resident #57 and # 53) out of 19 residents reviewed for abuse.
  15. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on record review and interview it was determined that the facility failed to thoroughly investigate allegations of abuse. This was evident for 2 facility reported incidents (#MD00187641 and #MD00201779) of 25 facility reported incidents investigated during the recertification survey.
  16. D
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on records review and interviews, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer in writing. This was evident in 1 (Resident #29) of 1 resident reviewed or hospitalization.
  17. D
    Assess the resident when there is a significant change in condition
    F637 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days following a significant decline in a resident's condition. This was evident for 1 (Resident #10) of 5 residents reviewed for unnecessary medications review.
  18. D
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    F676 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on medical record review, interview and observations it was determined that the facility failed to ensure staff assisted resident with wearing eyeglasses. This was found to be evident for 2 out of 3 residents reviewed for vision and hearing.
  19. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on record review and interview it was determined that the facility failed to provide residents with care for activities of daily living. This was evident for 1 complaint (#MD00205800) of 13 complaints reviewed during the recertification survey.
  20. D
    Provide activities to meet all resident's needs.
    F679 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on observations, medical record reviews, and staff interviews, it was determined that the facility failed to provide an activities program to meet the needs and preferences of residents. This was evident for 2 (Resident #10 and #34) of 2 residents reviewed for activities.
  21. 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.
    F688 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 31, 2025
    Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility failed to ensure that a resident with a limited range of motion received treatment and services as ordered by the attending provider to prevent further decline in the range of motion. This was evident for 2 (Resident #16 and #40) of 4 residents reviewed for position and mobility.
  22. D
    Provide safe, appropriate pain management for a resident who requires such services.
    F697 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to consistently document the reasons for administering an as-needed (PRN) pain medication and failed to document pain assessment to include the location of the pain and type of pain for a Resident reporting pain. This was evident for 1 (Resident #10) of 5 Residents reviewed for unnecessary medications review.
  23. D
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 31, 2025
    Inspectors wroteBased on medical record review and interviews, it was determined that the facility staff failed to obtain pre-dialysis treatment records for a resident. This was evident for 1 (Resident #37) of 1 resident reviewed for dialysis.
  24. 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.
    F726 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 31, 2025
    Inspectors wroteBased on record review and interview it was determined that the facility failed to employ competent nursing staff. This was evident during the Staffing task investigation, and for 1 complaint (#MD00205800) of 13 complaints reviewed during the recertification survey.
  25. D
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    F740 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 31, 2025
    Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure ordered 15 minute checks for suicidal ideation; and failed to report increase in agitation that resulted in the administration of Ativan without an order. This was found to be evident for 2 (Resident #234 and #66) out of 50 residents reviewed during the survey.
  26. D
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    F744 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 31, 2025
    Inspectors wroteBased on records review, observations and interviews, it was determined that the facility failed to ensure services provided to a resident with dementia are based on their choices and preferences. This was evident in 1 (Resident #57) of 4 residents reviewed for dementia care.
  27. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 31, 2025
    Inspectors wroteBased on medical record review, observations and staff interviews, it was determined that the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to ensure that an attending provider's orders for a resident's topical anesthetic medication included a time to remove it; and failed to provide adequate monitoring and indications for use of biological creams. This was evident for 1 (Resident #10) of 5 residents reviewed for unnecessary medications; and 1 (Resident #30) of 3 reviewed for pressure ulcers during this survey
  28. 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.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 31, 2025
    Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to document the specific reasons for administering a psychotropic medication and failed to implement non-pharmacological interventions (NPI) before administering the medicine as needed (PRN). This was evident for 1 (#10) of 5 Residents reviewed for unnecessary medications review.
  29. D
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on observations and records review, it was determined that the facility failed to ensure that medication error rates were below 5% during the completion of the medication administration facility task. This was evident for 2 of the 36 opportunities observed for the medication administration.
  30. D
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 31, 2025
    Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure a resident was free from a significant medication error. This was found to be evident for one (Resident #66) out of three resident with orders for as needed controlled medications reviewed during the investigation of drug diversion.
  31. D
    Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
    F776 · Administration · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 31, 2025
    Inspectors wroteBased on record review and interview it was determined that the facility failed to provide timely radiological services to its residents. This was evident for 1 facility reported incident (#MD00190908) of 25 facility reported incidents investigated during the recertification survey.
  32. D
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
    F836 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on review of facility staffing data and staff interviews, it was determined that the facility failed to ensure compliance with The Code of Maryland Regulations for Nursing Services - Staffing, 10.07.02.19 which states that A nursing home shall employ supervisory personnel and a sufficient number of support personnel to provide a minimum of 3 hours of bedside care per occupied bed per day, 7 days per week. by failing to ensure staffing at or above 3 hours of bedside care per patient per day (PPD). This was found to be evident for 63 out of 167 days reviewed.
  33. D
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    F838 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on records review and interviews, it was determined that the facility failed to have a facility assessment that was accurate and complete. This practice has the ability to affect all residents of the facility.
  34. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 31, 2025
    Inspectors wroteBased on record review and interview it was determined that the facility failed to accurately document resident records. This was evident for 2 (Resident #57, and #252) out of the 50 residents reviewed during the survey.
  35. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 31, 2025
    Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to ensure staff completed hand sanitation between dressing changes; and failed to have a physical barrier between the clean and soiled areas of the laundry room to prevent cross-contamination. This was found to be evident for one (Resident #34) out of three residents reviewed for pressure ulcers; and one out of one laundry room observed.
  36. D
    Keep all essential equipment working safely.
    F908 · Environmental · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 20, 2024
    Inspectors wroteBased on observation, interview and pertinent document review the facility failed to have a process in place to ensure an automated external defibrillator (AED), was maintained in a working order. This was evident for one automated external defibrillator out of 2 AEDs available in the facility.
  37. D
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    F919 · Environmental · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 31, 2025
    Inspectors wroteBased on observations, interviews and pertinent document review it was determined the facility failed to ensure that the resident's call system was functioning properly. This was found to be evident during random observations and had the potential to affect all resident rooms.
September 20, 2019Standard inspection · 6 citations
  1. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) November 30, 2019
    Inspectors wroteBased on observation and facility documentation review, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to follow transmission based precautions and using gloves to handle resident medications. This was evident for 1 (#11) of 1 staff observed passing ice water and 1 (#10) of 4 staff observed for medication administration.
  2. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 30, 2019
    Inspectors wroteBased on review of facility investigation, resident medical records, and interview with facility staff, it was determined that the facility failed to ensure that a resident remained free of verbal abuse. This was true for 2 (Residents #28 and # 2) of 5 residents reviewed for abuse.
  3. D
    Prepare residents for a safe transfer or discharge from the nursing home.
    F624 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 30, 2019
    Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident for 2 (#7, #58) of 2 residents reviewed for hospitalization.
  4. D
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 30, 2019
    Inspectors wroteBased on medication administration observation, medical record review and staff interview, it was determined the facility staff failed to ensure a medication error rate of less than 5 percent for 2 (#7, #16) of 12 residents observed with 31 medication administration opportunities which resulted in an error rate of 6.45% by 1 of 1 Licensed Practical Nurse and 1 of 3 certified medicine aides observed.
  5. D
    Keep all essential equipment working safely.
    F908 · Environmental · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 30, 2019
    Inspectors wroteBased on observation and staff interviews, it was determined that the facility did not have a process in place to ensure that all resident care equipment is maintained and calibrated to be in safe operating condition. This was noted for 1 of 4 certified medicine aides observed administering medications.
  6. C
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    F576 · Resident Rights · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) November 30, 2019
    Inspectors wroteBased on residents' interviews during the resident council meeting, it was determined that facility staff failed to ensure residents could receive and sent out mail on Saturdays.

Fire safety inspections

19 fire safety citations on file: 11 on March 6, 2026, 6 on November 26, 2024, 2 on September 20, 2019.

Every fire safety citation19 citations
  1. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · March 6, 2026 · Corrected (the home has a date of correction)
  2. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · March 6, 2026 · Corrected (the home has a date of correction)
  3. F
    Have simulated fire drills held at unexpected times.
    K 712 · March 6, 2026 · Corrected (the home has a date of correction)
  4. F
    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
    K 914 · March 6, 2026 · Corrected (the home has a date of correction)
  5. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · March 6, 2026 · Corrected (the home has a date of correction)
  6. E
    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
    K 223 · March 6, 2026 · Corrected (the home has a date of correction)
  7. E
    Have stairways and smokeproof enclosures used as exits that meet safety requirements.
    K 225 · March 6, 2026 · Corrected (the home has a date of correction)
  8. E
    Construct fire resistant interior walls.
    K 331 · March 6, 2026 · Corrected (the home has a date of correction)
  9. E
    Install corridor and hallway doors that block smoke.
    K 363 · March 6, 2026 · Corrected (the home has a date of correction)
  10. E
    Meet other general requirements that are deficient.
    K 500 · March 6, 2026 · Corrected (the home has a date of correction)
  11. E
    Have proper medical gas storage and administration areas.
    K 923 · March 6, 2026 · Corrected (the home has a date of correction)
  12. F
    Develop and maintain an Emergency Preparedness Program (EP).
    E 4 · November 26, 2024 · Corrected (the home has a date of correction)
  13. F
    Have stairways and smokeproof enclosures used as exits that meet safety requirements.
    K 225 · November 26, 2024 · Corrected (the home has a date of correction)
  14. F
    Install corridor and hallway doors that block smoke.
    K 363 · November 26, 2024 · Corrected (the home has a date of correction)
  15. F
    Have simulated fire drills held at unexpected times.
    K 712 · November 26, 2024 · Corrected (the home has a date of correction)
  16. F
    To conduct inspection, testing and maintenance of fire doors by qualified individuals.
    K 761 · November 26, 2024 · Corrected (the home has a date of correction)
  17. D
    Have proper medical gas storage and administration areas.
    K 923 · November 26, 2024 · Corrected (the home has a date of correction)
  18. D
    Have an externally vented heating system.
    K 522 · September 20, 2019 · Corrected (the home has a date of correction)
  19. B
    Install corridor and hallway doors that block smoke.
    K 363 · September 20, 2019 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
November 7, 2025Fine $15,106
November 26, 2024Fine $16,559
November 26, 2024Fine $16,562

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeMarylandUnited States
All nursing staff (RN, LPN and aides)3.503.873.86
Registered nurses0.750.840.69
All nursing staff on weekends3.133.473.42
Nurse aides1.98
Licensed practical nurses0.77
Nursing staff turnover (share who left in a year)48.4%40.2%45.8%
Registered nurse turnover33.3%38.7%42.9%
Administrators who left1

CMS expects 3.69 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.65 on weekdays and 3.13 on weekends, 14% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 8.8% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.43 in April to June 2025 to 3.50 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.500.753.653.13 8.8%0 of 9084
Oct to Dec 20253.560.633.643.34 9.3%0 of 9283
Jul to Sep 20253.330.653.443.06 11.3%0 of 9285
Apr to Jun 20253.430.543.513.22 24.2%0 of 9185
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Maryland, Jan to Mar 20263.730.743.883.348.0%0.1% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Maryland

JobMedianMiddle halfEmployed
Maryland, all employers
CNAs (nursing assistants)$20.79$18.46 to $22.0027,720
LPNs and LVNs$35.89$31.40 to $38.309,560
Registered nurses$47.98$40.26 to $51.6152,910
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

Work here? Share your pay anonymously

For Mountain City Rehab Center. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

Your job
Employed by
Usual shift
Do you get a shift differential?
Optional questions
Mandatory overtime?
How did staffing feel on your usual shift?

Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeMarylandUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
27.520.413.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.20.50.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
1.71.51.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
6.02.43.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
0.01.11.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
26.222.214.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
6.55.94.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
25.913.815.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
17.821.023.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
10.89.812.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
0.91.31.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.01.21.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Mountain City Rehab Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (54.2% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

54.2% this home

No different from the national rate

US median of homes 51.5% · Maryland: 90 better, 29 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 159 eligible stays.

Potentially preventable readmissions

11.8% this home

No different from the national rate

US median of homes 10.7% · Maryland: 0 better, 41 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 163 eligible stays.

Infections that led to a hospital stay

8.4% this home

No different from the national rate

US median of homes 7.1% · Maryland: 5 better, 6 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 113 eligible stays.

Self-care and mobility at discharge

38.5% this home

Median of homes: Maryland61.2% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 65 residents counted.

Falls with major injury

2.1% this home

Median of homes: Maryland0.4% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 93 residents counted.

New or worsened pressure ulcers

6.7% this home

Median of homes: Maryland2.4% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 93 residents counted.

Medication list given at discharge

100.0% this home

Median of homes: Maryland98.1% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 46 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: Legal Business Name Not Available.

NameRoleTypeShareSince
Ownership data not available

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 17 problems in this area, most recently on March 6, 2026: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 12 problems in this area, most recently on March 6, 2026: "Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies."
  3. How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 9 problems in this area, most recently on March 6, 2026: "Protect each resident from the wrongful use of the resident's belongings or money."
  4. When is the care plan meeting, and can family attend it?Inspectors cited 8 problems in this area, most recently on March 6, 2026: "Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.13 hours per resident per day, below the Maryland average of 3.47.
  6. How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.

Other nursing homes nearby

Maryland contacts for a concern about a nursing home

These are the official offices in Maryland. NursingHomeClear cannot take or act on complaints.

Common questions

What is Mountain City Rehab Center's Medicare star rating?
CMS rates Mountain City Rehab Center 1 out of 5 stars overall, with 1 for health inspections, 3 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Mountain City Rehab Center get at its last inspection?
13 health deficiencies at the standard inspection on March 6, 2026. The Maryland average is 17.
Has Mountain City Rehab Center been fined?
Yes. CMS lists 3 fines totaling $48,227 in the last three years.
Does Mountain City Rehab Center accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Mountain City Rehab Center?
CMS lists 1 owner or manager. Legal business name: Legal Business Name Not Available.

Sources

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