Cycle 1
Health 2025-03-25 · Fire 2025-03-25
21 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Rockville, MD
Potomac Valley Rehabilitation And Healthcare
4-star overall rating with 3-star inspections with 21 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
1235 Potomac Valley Road, Rockville, MD
(301) 762-0700
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
175
Certified beds
Average residents
165
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
59 facilities
Chain averages 2 overall / 2 health / 2 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
0.59
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.88
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.30
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.42
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
0.36
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.04
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
20%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,327
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.52
Composite VBP score used to determine payment impact.
Payment multiplier
1.0127
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.38
Baseline 20.25% · Performance 18.01% · Measure score 7.38 · Achievement 7.38 · Improvement 6.44
Healthcare-associated infections
6.31
Baseline 10.40% · Performance 6.72% · Measure score 6.31 · Achievement 3.74 · Improvement 6.31
Total nurse turnover
9.32
Baseline 49.69% · Performance 25.58% · Measure score 9.32 · Achievement 9.32 · Improvement 9
Adjusted total nurse staffing
0
Baseline 3.11 hours · Performance 3.07 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.77% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 415 · Observed rate 8.92% · Lower 95% interval 8.35% |
| Discharge to community | 49.87% |
50.57%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 386 · Observed rate 43.26% · Lower 95% interval 44.92% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.94% |
95.27%
3.7 pts better
|
Numerator 279 · Denominator 282 |
| Falls with major injury | 1.77% |
0.77%
1 pts worse
|
Numerator 5 · Denominator 282 |
| Discharge self-care score | 53.49% |
53.69%
0.2 pts worse
|
Numerator 92 · Denominator 172 |
| Discharge mobility score | 65.12% |
50.94%
14.2 pts better
|
Numerator 112 · Denominator 172 |
| Pressure ulcers or injuries, new or worsened | 3.9% |
2.29%
1.6 pts worse
|
Numerator 11 · Denominator 282 · Adjusted rate 3.38% |
| Healthcare-associated infections requiring hospitalization | 6.72% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 236 · Observed rate 5.51% · Lower 95% interval 4.47% |
| Staff COVID-19 vaccination coverage | 8.3% |
8.2%
0.1 pts better
|
Numerator 19 · Denominator 229 |
| Staff flu vaccination coverage | 65.45% |
42%
23.5 pts better
|
Numerator 144 · Denominator 220 |
| Discharge function score | 61.63% |
56.45%
5.2 pts better
|
Numerator 106 · Denominator 172 |
| Transfer of health information to provider | 98.78% |
95.95%
2.8 pts better
|
Numerator 162 · Denominator 164 |
| Transfer of health information to patient | 93.75% |
96.28%
2.5 pts worse
|
Numerator 75 · Denominator 80 |
| Resident COVID-19 vaccinations up to date | 43.98% |
25.2%
18.8 pts better
|
Numerator 73 · Denominator 166 |
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 0.9 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
91.9%
4.1 pts better
|
93.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 93.5% · Q3 97.7% · Q4 99.2% · 4Q avg 96.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
96.6%
0.7 pts better
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
2.3%
0.1 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.9% · Q3 2.3% · Q4 1.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 94.6% |
21.4%
73.2 pts worse
|
11.4%
83.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.3% · Q2 93.3% · Q3 95.9% · Q4 95.1% · 4Q avg 94.6% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
5.7%
0.5 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 5.4% · Q3 4.7% · Q4 4.8% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.1% |
16.1%
1 pts better
|
19.6%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 15.8% · Q3 14.6% · Q4 15.0% · 4Q avg 15.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.6% |
15.3%
12.3 pts worse
|
16.7%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 26.8% · Q3 25.0% · Q4 23.0% · 4Q avg 27.6% · 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 | 14.1% |
26.6%
12.5 pts better
|
16.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 12.7% · Q3 17.2% · Q4 15.6% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.7% |
22.9%
7.2 pts better
|
14.9%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 17.9% · Q3 17.3% · Q4 10.7% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.7%
0.5 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 0.0% · Q4 0.4% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.5%
0.6 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 1.5% · Q4 1.5% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.8% |
25.4%
0.6 pts better
|
19.8%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 21.9% · Q3 28.0% · Q4 21.5% · 4Q avg 24.8% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
6.3%
2.1 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.9% · Q3 5.6% · Q4 3.8% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.5% |
78.4%
8.1 pts better
|
81.7%
4.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.3% · Q2 86.9% · Q3 85.5% · Q4 87.9% · 4Q avg 86.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.6% |
9.9%
4.3 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 5.5% · Expected 10.8% · 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 0.9% · Q2 0.8% · Q3 1.4% · Q4 1.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.9% |
80.6%
14.3 pts better
|
79.7%
15.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.8% |
21.2%
2.4 pts better
|
23.9%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 19.1% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-09 · Fire 2020-01-09
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2018-11-15 · Fire 2018-11-15
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-19
F · Potential for more than minimal harm
2025-03-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-03-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-03-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-03-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-19
E · Potential for more than minimal harm
2025-03-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-03-25
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 2025-05-19
D · Potential for more than minimal harm
2025-03-25
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-03-25
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-03-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-19
E · Potential for more than minimal harm
2020-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-28
D · Potential for more than minimal harm
2020-01-09
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2020-02-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-10
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 2025-12-19
D · Potential for more than minimal harm
2025-10-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-10-10
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 2025-12-19
F · Potential for more than minimal harm
2025-03-25
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 2025-04-25
F · Potential for more than minimal harm
2025-03-25
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 2025-04-25
F · Potential for more than minimal harm
2025-03-25
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 2025-04-25
E · Potential for more than minimal harm
2025-03-25
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 2025-04-25
D · Potential for more than minimal harm
2025-03-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-25
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-25
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 2025-04-25
D · Potential for more than minimal harm
2025-03-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-25
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 2025-04-25
D · Potential for more than minimal harm
2025-03-25
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-25
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-25
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-25
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 2025-04-25
D · Potential for more than minimal harm
2025-03-25
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 2025-04-25
D · Potential for more than minimal harm
2025-03-25
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 2025-04-25
D · Potential for more than minimal harm
2025-03-25
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-03-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-25
D · Potential for more than minimal harm
2024-12-20
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 2025-01-20
D · Potential for more than minimal harm
2024-12-20
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 2025-01-20
E · Potential for more than minimal harm
2020-01-09
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 2020-02-28
D · Potential for more than minimal harm
2020-01-09
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 2020-02-28
D · Potential for more than minimal harm
2020-01-09
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2020-02-28
D · Potential for more than minimal harm
2020-01-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-02-28
B · Minimal harm
2020-01-09
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2020-02-28
D · Potential for more than minimal harm
2018-11-15
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 2018-12-30
D · Potential for more than minimal harm
2018-11-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-12-30
D · Potential for more than minimal harm
2018-11-15
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 2018-12-30
Penalties and ownership
What sits behind the stars
Ownership
Cp Health Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Arem, Aaron
5% Or Greater Indirect Ownership Interest · Individual
Arem, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Birnbaum, Israel
5% Or Greater Indirect Ownership Interest · Individual
Birnbaum, Israel
Corporate Director · Individual
Eze, Ezedube
Corporate Director · Individual
Eze, Ezedube
W-2 Managing Employee · Individual
Green, Dov
5% Or Greater Indirect Ownership Interest · Individual
Netzer, Michele
5% Or Greater Indirect Ownership Interest · Individual
Netzer, Michele
Corporate Director · Individual
Rma Equity LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Sterling Care Rockville Nursing
Rockville, MD
4-star overall rating with 3-star inspections with 23 recent health deficiencies with 23 fire-safety deficiencies in the latest cycle
#2
Collingswood Rehabilitation And Healthcare Center
Rockville, MD
2-star overall rating with 2-star inspections with 34 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#3
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
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