Cycle 1
Health 2024-09-30 · Fire 2024-09-30
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Potomac, MD
Montcare At Potomac
5-star overall rating with 5-star inspections with 10 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
10714 Potomac Tennis Lane, Potomac, MD
(301) 299-2453
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
168
Certified beds
Average residents
146
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1988-06-24
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
1.04
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.39
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.82
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.67
Higher values indicate more complex resident acuity
RN turnover
3%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
14%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,591
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9966
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.58
Baseline 17.74% · Performance 19.77% · Measure score 3.58 · Achievement 3.58 · Improvement 0
Healthcare-associated infections
3.87
Baseline 6.83% · Performance 6.68% · Measure score 3.87 · Achievement 3.87 · Improvement 0.31
Total nurse turnover
10
Baseline 20.20% · Performance 24.00% · Measure score 10 · Achievement 10 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.40 hours · Performance 2.81 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.66% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 639 · Observed rate 8.61% · Lower 95% interval 8.25% |
| Discharge to community | 66.28% |
50.57%
15.7 pts better
|
Better than the National Rate · Eligible stays 689 · Observed rate 64.01% · Lower 95% interval 62.21% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 425 · Denominator 425 |
| Falls with major injury | 0.24% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 425 |
| Discharge self-care score | 93.05% |
53.69%
39.4 pts better
|
Numerator 281 · Denominator 302 |
| Discharge mobility score | 83.77% |
50.94%
32.8 pts better
|
Numerator 253 · Denominator 302 |
| Pressure ulcers or injuries, new or worsened | 1.18% |
2.29%
1.1 pts better
|
Numerator 5 · Denominator 425 · Adjusted rate 0.88% |
| Healthcare-associated infections requiring hospitalization | 6.68% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 398 · Observed rate 5.78% · Lower 95% interval 4.54% |
| Staff COVID-19 vaccination coverage | 16.78% |
8.2%
8.6 pts better
|
Numerator 25 · Denominator 149 |
| Staff flu vaccination coverage | 95.62% |
42%
53.6 pts better
|
Numerator 131 · Denominator 137 |
| Discharge function score | 92.38% |
56.45%
35.9 pts better
|
Numerator 279 · Denominator 302 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 86 · Denominator 86 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 299 · Denominator 299 |
| Resident COVID-19 vaccinations up to date | 29.26% |
25.2%
4.1 pts better
|
Numerator 67 · Denominator 229 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.3
0.2 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.3 · Expected 1.2 · 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 | 2.0% |
2.3%
0.3 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.0% · Q3 2.9% · Q4 3.1% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 80.2% |
21.4%
58.8 pts worse
|
11.4%
68.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 77.8% · Q2 72.0% · Q3 78.8% · Q4 91.8% · 4Q avg 80.2% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
5.7%
0.5 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 9.3% · Q3 5.4% · Q4 6.6% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.6% |
16.1%
4.5 pts worse
|
19.6%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 20.0% · Q3 22.1% · Q4 21.5% · 4Q avg 20.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.5% |
15.3%
3.8 pts better
|
16.7%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 11.4% · Q3 12.2% · Q4 11.2% · 4Q avg 11.5% · 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 | 7.3% |
26.6%
19.3 pts better
|
16.3%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.8% · Q3 13.1% · Q4 6.5% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.6% |
22.9%
12.3 pts better
|
14.9%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 9.1% · Q3 13.6% · Q4 8.9% · 4Q avg 10.6% · 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 | 0.5% |
1.5%
1 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.8% |
25.4%
2.6 pts better
|
19.8%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 15.9% · Q3 20.7% · Q4 25.1% · 4Q avg 22.8% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
6.3%
0.6 pts better
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 4.9% · Q3 4.7% · Q4 5.0% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
78.4%
21.2 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.7% · Q4 98.5% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
9.9%
4.5 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 4.4% · Expected 9.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.3%
0.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.7% · Q3 0.4% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.5% |
80.6%
18.9 pts better
|
79.7%
19.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.4% |
21.2%
1.8 pts better
|
23.9%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 16.2% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-10 · Fire 2019-10-10
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2018-08-03 · Fire 2018-08-03
4 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-04
F · Potential for more than minimal harm
2024-09-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-04
F · Potential for more than minimal harm
2024-09-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-04
F · Potential for more than minimal harm
2024-09-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-09-30
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-09-30
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-09-30
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-09-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-09-30
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-09-30
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-09-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-09-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-09-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-04
C · Minimal harm
2019-10-10
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-11-01
C · Minimal harm
2018-08-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2018-10-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-30
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 2024-10-28
D · Potential for more than minimal harm
2024-09-30
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-30
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 2024-10-28
D · Potential for more than minimal harm
2024-09-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-30
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-30
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 2024-10-28
D · Potential for more than minimal harm
2024-09-30
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 2024-10-28
D · Potential for more than minimal harm
2024-09-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-28
D · Potential for more than minimal harm
2019-10-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-11-20
B · Minimal harm
2019-10-10
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 2019-11-20
E · Potential for more than minimal harm
2018-08-03
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 2018-09-04
E · Potential for more than minimal harm
2018-08-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-09-04
B · Minimal harm
2018-08-03
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2018-09-04
B · Minimal harm
2018-08-03
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 2018-09-04
Penalties and ownership
What sits behind the stars
Ownership
Md3 Operator Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Mermelstein, Boruch
5% Or Greater Indirect Ownership Interest · Individual
Green, Dov
5% Or Greater Indirect Ownership Interest · Individual
Zager, Nachum
5% Or Greater Indirect Ownership Interest · Individual
Poulsen, Cherilyn
W-2 Managing Employee · Individual
Zager, Nachum
Operational/Managerial Control · Individual
Zager, Nachum
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
The Village At Rockville
Rockville, MD
3-star overall rating with 2-star inspections with $17,345 in total fines with 21 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Potomac Valley Rehabilitation And Healthcare
Rockville, MD
4-star overall rating with 3-star inspections with 21 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Montcare At Bethesda
Bethesda, MD
5-star overall rating with 4-star inspections with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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