Cycle 1
Health 2020-09-16 · Fire 2020-09-16
16 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Silver Spring, MD
Complete Care At Springbrook
4-star overall rating with 3-star inspections with 16 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
12325 New Hampshire Avenue, Silver Spring, MD
(301) 622-4600
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
93
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1976-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
Hours and turnover
RN hours / resident day
0.60
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.80
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.33
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
2.79
CMS adjusted total nurse staffing hours
Case-mix index
1.63
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,799
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.57
Baseline 21.30% · Performance 21.17% · Measure score 0.57 · Achievement 0.57 · Improvement 0
Healthcare-associated infections
0
Baseline 8.42% · Performance 9.43% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.71
Baseline 33.33% · Performance 44.44% · Measure score 4.71 · Achievement 4.71 · Improvement 0
Adjusted total nurse staffing
0.81
Baseline 2.95 hours · Performance 3.31 hours · Measure score 0.81 · Achievement 0.81 · Improvement 0.77
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.84% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 158 · Observed rate 13.92% · Lower 95% interval 7.98% |
| Discharge to community | 54.35% |
50.57%
3.8 pts better
|
No Different than the National Rate · Eligible stays 169 · Observed rate 42.01% · Lower 95% interval 44.53% |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 144 · Denominator 144 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 144 |
| Discharge self-care score | 65.71% |
53.69%
12 pts better
|
Numerator 23 · Denominator 35 |
| Discharge mobility score | 48.57% |
50.94%
2.4 pts worse
|
Numerator 17 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 2.08% |
2.29%
0.2 pts better
|
Numerator 3 · Denominator 144 · Adjusted rate 1.47% |
| Healthcare-associated infections requiring hospitalization | 9.42% |
7.12%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 121 · Observed rate 14.05% · Lower 95% interval 6.42% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 107 |
| Staff flu vaccination coverage | 95.28% |
42%
53.3 pts better
|
Numerator 101 · Denominator 106 |
| Discharge function score | 68.57% |
56.45%
12.1 pts better
|
Numerator 24 · Denominator 35 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 80 · Denominator 80 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 37 · Denominator 37 |
| Resident COVID-19 vaccinations up to date | 18.92% |
25.2%
6.3 pts worse
|
Numerator 14 · Denominator 74 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.3
0.7 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.4 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.9%
8.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.6%
3.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
2.3%
1.2 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 1.5% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 71.7% |
21.4%
50.3 pts worse
|
11.4%
60.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 66.7% · Q2 72.2% · Q3 73.6% · Q4 74.6% · 4Q avg 71.7% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
5.7%
3 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 1.6% · Q3 3.1% · Q4 0.0% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.5% |
16.1%
9.6 pts better
|
19.6%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 6.5% · Q3 7.7% · Q4 6.0% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.1% |
15.3%
9.2 pts better
|
16.7%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 6.4% · Q3 4.8% · Q4 4.3% · 4Q avg 6.1% · 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 | 11.8% |
26.6%
14.8 pts better
|
16.3%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.5% |
22.9%
2.4 pts better
|
14.9%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 15.5% · Q3 22.2% · Q4 20.6% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.5%
1.1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.7% |
25.4%
0.7 pts better
|
19.8%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 28.1% · Q3 27.0% · Q4 23.0% · 4Q avg 24.7% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
6.3%
2.5 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.6% · Q3 3.4% · Q4 3.9% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
78.4%
20.3 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 98.5% · Q3 97.9% · Q4 100.0% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
9.9%
1.6 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 8.6% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.4% · Q4 1.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
80.6%
19.4 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
21.2%
6.7 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 33.3% · Expected 28.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-09-12 · Fire 2019-09-12
13 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-03-29 · Fire 2019-03-29
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2020-09-16
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2020-09-27
D · Potential for more than minimal harm
2019-09-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-10-11
C · Minimal harm
2019-09-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-10-11
D · Potential for more than minimal harm
2019-03-29
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2019-05-17
D · Potential for more than minimal harm
2019-03-29
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-05-17
C · Minimal harm
2019-03-29
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-05-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-19
E · Potential for more than minimal harm
2025-12-19
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2026-01-19
E · Potential for more than minimal harm
2025-12-19
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 2026-01-19
D · Potential for more than minimal harm
2025-12-19
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-19
D · Potential for more than minimal harm
2025-12-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2026-01-19
D · Potential for more than minimal harm
2025-12-19
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 2026-01-19
E · Potential for more than minimal harm
2025-03-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-14
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 2025-04-30
D · Potential for more than minimal harm
2025-03-14
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-04-30
D · Potential for more than minimal harm
2024-12-18
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 2025-01-27
D · Potential for more than minimal harm
2024-12-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-18
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 2025-01-27
D · Potential for more than minimal harm
2024-12-18
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 2025-01-27
E · Potential for more than minimal harm
2020-09-16
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 2020-10-16
E · Potential for more than minimal harm
2020-09-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-10-16
D · Potential for more than minimal harm
2020-09-16
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2020-10-16
D · Potential for more than minimal harm
2020-09-16
F585 · Resident Rights Deficiencies
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 2020-10-16
D · Potential for more than minimal harm
2020-09-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-10-16
D · Potential for more than minimal harm
2020-09-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-10-16
D · Potential for more than minimal harm
2020-09-16
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2020-10-16
E · Potential for more than minimal harm
2019-09-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-10-28
D · Potential for more than minimal harm
2019-09-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-10-28
D · Potential for more than minimal harm
2019-09-12
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 2019-10-28
D · Potential for more than minimal harm
2019-09-12
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 2019-10-28
D · Potential for more than minimal harm
2019-09-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-10-28
D · Potential for more than minimal harm
2019-09-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-10-28
B · Minimal harm
2019-09-12
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-10-28
B · Minimal harm
2019-09-12
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 2019-10-28
J · Immediate jeopardy
2019-03-29
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 2019-01-24
E · Potential for more than minimal harm
2019-03-29
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2019-05-17
D · Potential for more than minimal harm
2019-03-29
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2019-05-17
D · Potential for more than minimal harm
2019-03-29
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2019-05-17
D · Potential for more than minimal harm
2019-03-29
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 2019-05-17
D · Potential for more than minimal harm
2019-03-29
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 2019-05-17
D · Potential for more than minimal harm
2019-03-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-05-17
D · Potential for more than minimal harm
2019-03-29
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 2019-05-17
D · Potential for more than minimal harm
2019-03-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-05-17
D · Potential for more than minimal harm
2019-03-29
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 2019-05-17
Penalties and ownership
What sits behind the stars
Ownership
Pc Md5 Opco Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Cox, Vickie
Operational/Managerial Control · Individual
Dave, Mitul
Operational/Managerial Control · Individual
Eludoyin, Oludapo
Operational/Managerial Control · Individual
Mansfield, Melissa
Operational/Managerial Control · Individual
Pc Md5 Topco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Silverberg, Nisanel
Operational/Managerial Control · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Sternbuch, Daniel
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Silver Spring Healthcare Center
Silver Spring, MD
2-star overall rating with 1-star inspections with $48,529 in total fines with 24 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Fairland Center
Silver Spring, MD
2-star overall rating with 2-star inspections with 31 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Autumn Lake Healthcare At Silver Spring
Silver Spring, MD
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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