Cycle 1
Health 2025-04-01 · Fire 2025-04-01
16 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Sandy Spring, MD
Brooke Grove Rehab. & Nsg Ctr
3-star overall rating with 3-star inspections with 16 recent health deficiencies
18131 Slade School Road, Sandy Spring, MD
(301) 924-5176
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
190
Certified beds
Average residents
168
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-06-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
Hours and turnover
RN hours / resident day
0.98
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.46
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.24
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.75
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
3.72
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
860
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.88
Composite VBP score used to determine payment impact.
Payment multiplier
1.0177
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.65
Baseline 17.92% · Performance 17.89% · Measure score 7.65 · Achievement 7.65 · Improvement 0
Healthcare-associated infections
8.03
Baseline 6.96% · Performance 5.44% · Measure score 8.03 · Achievement 8.03 · Improvement 7.26
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.18
Baseline 4.16 hours · Performance 3.98 hours · Measure score 3.18 · Achievement 3.18 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.66% |
10.72%
2.9 pts worse
|
Worse than the National Rate · Eligible stays 1062 · Observed rate 12.24% · Lower 95% interval 11.66% |
| Discharge to community | 54.6% |
50.57%
4 pts better
|
Better than the National Rate · Eligible stays 1051 · Observed rate 52.33% · Lower 95% interval 51.16% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.56% |
95.27%
3.3 pts better
|
Numerator 618 · Denominator 627 |
| Falls with major injury | 1.28% |
0.77%
0.5 pts worse
|
Numerator 8 · Denominator 627 |
| Discharge self-care score | 39.45% |
53.69%
14.2 pts worse
|
Numerator 187 · Denominator 474 |
| Discharge mobility score | 59.28% |
50.94%
8.3 pts better
|
Numerator 281 · Denominator 474 |
| Pressure ulcers or injuries, new or worsened | 4.47% |
2.29%
2.2 pts worse
|
Numerator 28 · Denominator 627 · Adjusted rate 4.15% |
| Healthcare-associated infections requiring hospitalization | 5.44% |
7.12%
1.7 pts better
|
Better than the National Rate · Eligible stays 649 · Observed rate 4.16% · Lower 95% interval 4.14% |
| Staff COVID-19 vaccination coverage | 6.65% |
8.2%
1.5 pts worse
|
Numerator 21 · Denominator 316 |
| Staff flu vaccination coverage | 75.18% |
42%
33.2 pts better
|
Numerator 206 · Denominator 274 |
| Discharge function score | 49.37% |
56.45%
7.1 pts worse
|
Numerator 234 · Denominator 474 |
| Transfer of health information to provider | 99.21% |
95.95%
3.3 pts better
|
Numerator 252 · Denominator 254 |
| Transfer of health information to patient | 99.34% |
96.28%
3.1 pts better
|
Numerator 301 · Denominator 303 |
| Resident COVID-19 vaccinations up to date | 29.19% |
25.2%
4 pts better
|
Numerator 94 · Denominator 322 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.3
About the same
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 77.1% |
91.9%
14.8 pts worse
|
93.4%
16.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.7% · Q2 69.3% · Q3 78.9% · Q4 84.7% · 4Q avg 77.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.6% |
96.6%
6 pts worse
|
95.5%
4.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
2.3%
1.6 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 0.9% · Q4 0.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.0% |
21.4%
13.4 pts better
|
11.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 8.7% · Q3 7.0% · Q4 8.7% · 4Q avg 8.0% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
5.7%
1.4 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 10.1% · Q3 8.7% · Q4 3.9% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.0% |
16.1%
3.9 pts worse
|
19.6%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 18.4% · Q3 22.4% · Q4 20.0% · 4Q avg 20.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.8% |
15.3%
2.5 pts better
|
16.7%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 17.3% · Q3 12.0% · Q4 8.3% · 4Q avg 12.8% · 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 | 46.7% |
26.6%
20.1 pts worse
|
16.3%
30.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 46.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 37.6% |
22.9%
14.7 pts worse
|
14.9%
22.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.7% · Q2 42.0% · Q3 31.2% · Q4 35.3% · 4Q avg 37.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.7%
0.2 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
1.5%
1.9 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.5% · Q3 3.8% · Q4 1.8% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.1% |
25.4%
2.3 pts better
|
19.8%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 30.8% · Q3 14.1% · Q4 20.4% · 4Q avg 23.1% |
| Percentage of long-stay residents with pressure ulcers | 8.3% |
6.3%
2 pts worse
|
5.1%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 11.8% · Q3 6.9% · Q4 6.8% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.6% |
78.4%
0.8 pts worse
|
81.7%
4.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 73.4% · Q2 74.2% · Q3 81.4% · Q4 82.1% · 4Q avg 77.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.2% |
9.9%
2.7 pts better
|
12.0%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.2% · Observed 6.8% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.3%
0.4 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.8% · Q3 0.8% · Q4 0.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.7% |
80.6%
4.1 pts better
|
79.7%
5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.4% |
21.2%
2.8 pts better
|
23.9%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.4% · Observed 18.8% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-02-28 · Fire 2020-02-28
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2019-02-15 · Fire 2019-02-15
15 health deficiencies
Top issue: Resident Rights (5 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2020-02-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-03-03
D · Potential for more than minimal harm
2019-02-15
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2019-03-20
C · Minimal harm
2019-02-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-03-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-04-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-04-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-01
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-04-01
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-01
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-01
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-01
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-01
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-01
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-01
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-01
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-05-16
D · Potential for more than minimal harm
2020-02-28
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2020-03-27
D · Potential for more than minimal harm
2020-02-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2020-03-27
D · Potential for more than minimal harm
2020-02-28
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2020-03-27
D · Potential for more than minimal harm
2020-02-28
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2020-03-27
D · Potential for more than minimal harm
2020-02-28
F761 · Pharmacy Service Deficiencies
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 2020-03-27
D · Potential for more than minimal harm
2020-02-28
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2020-03-27
D · Potential for more than minimal harm
2020-02-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-03-27
B · Minimal harm
2020-02-28
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2020-03-27
E · Potential for more than minimal harm
2019-02-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-03-20
E · Potential for more than minimal harm
2019-02-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-03-20
E · Potential for more than minimal harm
2019-02-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-03-20
D · Potential for more than minimal harm
2019-02-15
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2019-03-20
D · Potential for more than minimal harm
2019-02-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-03-20
D · Potential for more than minimal harm
2019-02-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-03-20
D · Potential for more than minimal harm
2019-02-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-03-20
D · Potential for more than minimal harm
2019-02-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-03-20
D · Potential for more than minimal harm
2019-02-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-03-20
D · Potential for more than minimal harm
2019-02-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-20
B · Minimal harm
2019-02-15
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2019-03-20
B · Minimal harm
2019-02-15
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-03-20
B · Minimal harm
2019-02-15
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-03-20
B · Minimal harm
2019-02-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-03-20
B · Minimal harm
2019-02-15
F761 · Pharmacy Service Deficiencies
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 2019-03-20
Penalties and ownership
What sits behind the stars
Ownership
Brooks, Carolyn
Corporate Director · Individual
Davidson, Kevin
Corporate Director · Individual
Hunter, Dennis
Operational/Managerial Control · Individual
Hunter, Dennis
Corporate Director · Individual
Hunter, Dennis
Corporate Officer · Individual
Malin, Wesley
Corporate Director · Individual
Malin, Wesley
Corporate Officer · Individual
Mazzeo, Kelly
Corporate Director · Individual
Ndahayo, Joviah
Corporate Director · Individual
Spillane, Keith
Corporate Officer · Individual
Wetmore, Thomas
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Friends Nursing Home
Sandy Spring, MD
5-star overall rating with 4-star inspections with $22,965 in total fines with 8 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Bedford Court Healthcare Cent.
Silver Spring, MD
5-star overall rating with 4-star inspections with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Layhill Nursing And Rehabilitation Center
Silver Spring, MD
1-star overall rating with 1-star inspections with Special Focus status with $153,596 in total fines with 57 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
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