Cycle 1
Health 2025-03-13 · Fire 2025-03-13
43 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Rockville, MD
Shady Grove Nursing And Rehabilitation Center
2-star overall rating with 1-star inspections with $12,735 in total fines with 43 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
9701 Medical Center Drive, Rockville, MD
(301) 315-1900
Overall
2 / 5
CMS overall stars
Health inspections
1 / 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
144
Certified beds
Average residents
132
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifeworks Rehab
Operator or chain grouping
Approved since
1987-06-05
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
0.57
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.74
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.03
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.37
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
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
45%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,072
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.97
Composite VBP score used to determine payment impact.
Payment multiplier
1.0064
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.90
Baseline 23.72% · Performance 18.77% · Measure score 6.90 · Achievement 5.75 · Improvement 6.90
Healthcare-associated infections
7.45
Baseline 11.96% · Performance 6.42% · Measure score 7.45 · Achievement 4.72 · Improvement 7.45
Total nurse turnover
6.43
Baseline 57.89% · Performance 37.39% · Measure score 6.43 · Achievement 6.43 · Improvement 5.71
Adjusted total nurse staffing
0
Baseline 3.45 hours · Performance 3.10 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.94% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 343 · Observed rate 10.2% · Lower 95% interval 8.68% |
| Discharge to community | 57.69% |
50.57%
7.1 pts better
|
Better than the National Rate · Eligible stays 322 · Observed rate 51.24% · Lower 95% interval 51.54% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 245 · Denominator 245 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 245 |
| Discharge self-care score | 54.36% |
53.69%
0.7 pts better
|
Numerator 81 · Denominator 149 |
| Discharge mobility score | 64.43% |
50.94%
13.5 pts better
|
Numerator 96 · Denominator 149 |
| Pressure ulcers or injuries, new or worsened | 2.45% |
2.29%
0.2 pts worse
|
Numerator 6 · Denominator 245 · Adjusted rate 2.2% |
| Healthcare-associated infections requiring hospitalization | 6.42% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 235 · Observed rate 5.96% · Lower 95% interval 4.18% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 156 |
| Staff flu vaccination coverage | 92.16% |
42%
50.2 pts better
|
Numerator 141 · Denominator 153 |
| Discharge function score | 63.09% |
56.45%
6.6 pts better
|
Numerator 94 · Denominator 149 |
| Transfer of health information to provider | 97.67% |
95.95%
1.7 pts better
|
Numerator 126 · Denominator 129 |
| Transfer of health information to patient | 88.24% |
96.28%
8 pts worse
|
Numerator 75 · Denominator 85 |
| Resident COVID-19 vaccinations up to date | 38.66% |
25.2%
13.5 pts better
|
Numerator 46 · Denominator 119 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.3
0.4 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.2
0.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.0% |
91.9%
1.1 pts better
|
93.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.1% · Q2 93.4% · Q3 95.2% · Q4 90.3% · 4Q avg 93.0% |
| 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 | 1.2% |
2.3%
1.1 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.9% · Q3 1.0% · Q4 1.9% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 79.1% |
21.4%
57.7 pts worse
|
11.4%
67.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.3% · Q2 70.2% · Q3 81.1% · Q4 86.2% · 4Q avg 79.1% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
5.7%
2.8 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 2.0% · Q3 3.2% · Q4 1.1% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.6% |
16.1%
5.5 pts better
|
19.6%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 7.9% · Q3 11.7% · Q4 12.6% · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.4% |
15.3%
10.1 pts worse
|
16.7%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 27.7% · Q3 25.3% · Q4 21.5% · 4Q avg 25.4% · 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 | 5.7% |
26.6%
20.9 pts better
|
16.3%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.3% · Q3 5.1% · Q4 10.2% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.8% |
22.9%
14.1 pts better
|
14.9%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 10.1% · Q3 0.0% · Q4 15.1% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.7%
0.1 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.5% · 4Q avg 0.6% · 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 1.0% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.7% |
25.4%
2.7 pts better
|
19.8%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 33.6% · Q3 13.5% · Q4 17.8% · 4Q avg 22.7% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
6.3%
0.1 pts better
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 7.1% · Q3 3.5% · Q4 7.2% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
78.4%
15.8 pts better
|
81.7%
12.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 91.9% · Q3 91.6% · Q4 96.9% · 4Q avg 94.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
9.9%
3.9 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 6.2% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.3%
0.2 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.7% · Q3 1.7% · Q4 1.8% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.0% |
80.6%
7.4 pts better
|
79.7%
8.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
21.2%
2.4 pts worse
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 23.9% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-01-15 · Fire 2021-01-15
24 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-04-12 · Fire 2019-04-12
17 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-13
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 2025-03-24
F · Potential for more than minimal harm
2025-03-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-24
F · Potential for more than minimal harm
2025-03-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-24
F · Potential for more than minimal harm
2025-03-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-24
E · Potential for more than minimal harm
2025-03-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-24
E · Potential for more than minimal harm
2025-03-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-03-13
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-03-13
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-03-13
K525 · Services Deficiencies
Fire Safety
Enure that solid fuel-burning fireplaces are not in patient sleeping areas.
Corrected 2025-03-24
F · Potential for more than minimal harm
2021-01-15
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2021-02-09
D · Potential for more than minimal harm
2021-01-15
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 2021-02-09
D · Potential for more than minimal harm
2021-01-15
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 2021-02-09
C · Minimal harm
2021-01-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-02-09
C · Minimal harm
2021-01-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-02-09
C · Minimal harm
2021-01-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-02-09
F · Potential for more than minimal harm
2019-04-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-07-30
E · Potential for more than minimal harm
2019-04-12
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 2019-07-30
D · Potential for more than minimal harm
2019-04-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-07-30
C · Minimal harm
2019-04-12
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2019-07-30
C · Minimal harm
2019-04-12
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2019-07-30
C · Minimal harm
2019-04-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-07-30
C · Minimal harm
2019-04-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-07-30
C · Minimal harm
2019-04-12
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-07-30
C · Minimal harm
2019-04-12
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-07-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-19
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 2026-01-27
D · Potential for more than minimal harm
2025-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-27
D · Potential for more than minimal harm
2025-07-17
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2025-08-11
G · Actual harm
2025-06-16
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 2025-08-14
D · Potential for more than minimal harm
2025-06-16
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-08-14
D · Potential for more than minimal harm
2025-06-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-14
D · Potential for more than minimal harm
2025-06-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-08-14
F · Potential for more than minimal harm
2025-03-13
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 2025-05-05
E · Potential for more than minimal harm
2025-03-13
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 2025-05-05
E · Potential for more than minimal harm
2025-03-13
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 2025-05-05
E · Potential for more than minimal harm
2025-03-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-05
E · Potential for more than minimal harm
2025-03-13
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 2025-05-05
E · Potential for more than minimal harm
2025-03-13
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 2025-05-05
E · Potential for more than minimal harm
2025-03-13
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 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
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 2025-05-05
D · Potential for more than minimal harm
2025-03-13
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 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
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 2025-05-05
D · Potential for more than minimal harm
2025-03-13
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 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
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 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
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 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
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 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
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 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
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 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
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 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-05-05
D · Potential for more than minimal harm
2025-03-13
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2025-05-05
D · Potential for more than minimal harm
2024-03-26
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-26
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 2024-04-29
D · Potential for more than minimal harm
2024-03-26
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 2024-04-29
D · Potential for more than minimal harm
2024-03-26
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-26
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 2024-04-29
D · Potential for more than minimal harm
2024-03-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-26
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-26
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 2024-04-29
D · Potential for more than minimal harm
2024-03-26
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2024-04-29
F · Potential for more than minimal harm
2021-01-15
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2021-03-05
E · Potential for more than minimal harm
2021-01-15
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 2021-03-05
E · Potential for more than minimal harm
2021-01-15
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2021-03-05
E · Potential for more than minimal harm
2021-01-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-03-05
E · Potential for more than minimal harm
2021-01-15
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2021-03-05
E · Potential for more than minimal harm
2021-01-15
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 2021-03-05
E · Potential for more than minimal harm
2021-01-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-03-05
D · Potential for more than minimal harm
2021-01-15
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 2021-03-05
D · Potential for more than minimal harm
2021-01-15
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 2021-03-05
D · Potential for more than minimal harm
2021-01-15
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 2021-03-05
D · Potential for more than minimal harm
2021-01-15
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 2021-03-05
D · Potential for more than minimal harm
2021-01-15
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 2021-03-05
D · Potential for more than minimal harm
2021-01-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-03-05
D · Potential for more than minimal harm
2021-01-15
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 2021-03-05
F · Potential for more than minimal harm
2019-04-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-24
E · Potential for more than minimal harm
2019-04-12
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 2019-05-24
D · Potential for more than minimal harm
2019-04-12
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 2019-05-24
D · Potential for more than minimal harm
2019-04-12
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 2019-05-24
D · Potential for more than minimal harm
2019-04-12
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-04-12
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 2019-05-24
D · Potential for more than minimal harm
2019-04-12
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 2019-05-24
D · Potential for more than minimal harm
2019-04-12
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 2019-05-24
D · Potential for more than minimal harm
2019-04-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-04-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-04-12
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 2019-05-24
D · Potential for more than minimal harm
2019-04-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-04-12
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 2019-05-24
D · Potential for more than minimal harm
2019-04-12
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 2019-05-24
C · Minimal harm
2019-04-12
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 2019-05-24
B · Minimal harm
2019-04-12
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 2019-05-24
B · Minimal harm
2019-04-12
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 2019-05-24
Penalties and ownership
What sits behind the stars
$12,735
2025-06-16
Fine
Fine · fine $12,735
Fine
Ownership
Thunder Health Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Birnbaum, Israel
5% Or Greater Indirect Ownership Interest · Individual
Netzer, Michele
5% Or Greater Indirect Ownership Interest · Individual
Kohn, Avrohom
5% Or Greater Indirect Ownership Interest · Individual
Rma Equity LLC
5% Or Greater Indirect Ownership Interest · Organization
Birnbaum, Israel
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Ingleside At King Farm
Rockville, MD
5-star overall rating with 4-star inspections with 14 recent health deficiencies with 4 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
Jump out