Montcare at Potomac
10714 Potomac Tennis Lane, Potomac, MD 20854 · Montgomery County · (301) 299-2453
168 certified beds, about 156 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1988
CMS high performing icon Certified for Medicaid Certified for Medicare
Overall
5 of 5
Health inspections
4 of 5
Staffing
4 of 5
Quality measures
5 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 215171 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on February 18, 2026, inspectors cited 8 health deficiencies (the Maryland average is 17, the national average 9.2).
None of its 21 health citations since October 2019 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.69 hours per resident per day, against 3.87 across Maryland and 3.86 nationally. Registered nurses accounted for 1.01 of those hours.
16.7% of nursing staff left within the year CMS measured (Maryland average 40.2%).
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
210/19
1109/24
802/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 21 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
20D
0E
0F
Potential for minimal harm
0A
1B
0C
February 18, 2026Standard inspection · 8 citations
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded, including coding related to wander/elopement risk status. This was evident for 2 (Residents #108 and #154) out of 5 residents reviewed for accidents during the recertification survey.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to develop and implement comprehensive care plan regarding the use of a nebulizer. This was evident for 1 (Residents #1) of 41 residents reviewed for care planning during the recertification survey.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, clinical record reviews and interviews, it was determined that the facility failed to review and revise care plans to meet the specific needs of the residents. This was evident of 3 (Residents #4, #111 and #91) out of 41 residents reviewed for care plan timing and revision during the recertification survey.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide necessary personal hygiene to dependent residents. This was evident for 2 (Residents #111 and #91) of 5 residents reviewed for Activities of Daily Living (ADLs) during the recertification survey.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to provide residents with necessary respiratory care services consistent with professional standards. This was evident for 3 (Resident #28, #4 and #1) out of 4 residents reviewed for respiratory care during the recertification survey.
- D Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, record review and interviews, it was determined that the facility failed to ensure a resident received medication according to the physician's orders. This was evident for 1 (Resident #31) of 6 residents reviewed for unnecessary medications.
- D 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.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interviews, and review of facility policy, the facility failed to ensure opened insulin pens were labeled with the date opened as required by policy. This was evident in 1 of 5 medication carts observed during the annual survey.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interviews, it was determined that the facility failed to ensure appropriate infection prevention and control practices were followed. This was evident for 1 of 1 observation in the laundry room.
September 30, 2024Standard inspection, Complaint inspection · 11 citations
- D Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure the call bell device was within reach of a resident (Resident #28). This was evident for 1 out of 34 facility residents observed by the surveyor during initial tours during the facility's recertification survey.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of facility reported incident investigation and interview, it was determined the facility staff failed to report a possible misappropriation of resident property within 24 hours of the incident to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (Resident #48) of 12 residents reviewed for abuse during a recertification/complaint survey.
- D 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.
Inspectors wroteBased on a medical record review and staff interview, it was determined that the facility failed to ensure that the physician documented a resident's discharge in the medical record. This was identified for one (Resident # 152) of three residents reviewed for discharge during the recertification/complaint survey.
- D Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative (RP) in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 2 (#136, #70) of 4 residents reviewed for hospitalization during a recertification/complaint survey.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview it was determined the facility failed to ensure a resident (Resident #81) received a recommended specialist follow up appointment after a hospitalization. This was evident for 1 out of 4 residents reviewed for hospitalization during the facility's recertification/complaint survey.
- D Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review, policy review, and staff interview, it was determined that the facility failed to monitor and evaluate residents' weight gain and notify the physician. This was evidenced by 1 (Resident #145) out of 3 residents reviewed for nutrition during the recertification/complaint survey.
- D Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observations, record reviews, and resident and staff interviews, it was determined that the facility failed to evaluate and manage residents' pain consistently. This was evident for one resident (# 97) of four residents who were reviewed for pain during the recertification/complaint survey.
- D Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to follow physician orders by administering as needed (PRN) pain medication outside the prescribed parameters. By failing to follow the prescribed parameters for the medication administration, the resident was given an unnecessary medication. This was identified for 1 (#203) of 5 residents reviewed for unnecessary medications during a recertification/complaint survey.
- D 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.
Inspectors wroteBased on observation and interview it was determined facility staff failed to 1) safely store a resident's medication (Resident #42), and 2) dispose of expired medications and dressing supplies. This was evident on 2 of 3 nursing units observed during a recertification/complaint survey.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for Resident (#70). This was evident for 1 of 54 residents selected for review during the recertification/complaint survey.
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to provide education regarding the benefits and potential side effects of the influenza and pneumococcal vaccine. This was evidenced for 1 (Resident #29) of 5 residents reviewed for Influenza and Pneumococcal Immunizations records during the recertification/complaint survey.
October 10, 2019Standard inspection · 2 citations
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on surveyor review of the clinical record and facility staff interview, it was determined that the facility failed to provide services consistent with physician orders and professional standards of practice. This finding was evident in 1 of 32 residents selected for review during the survey (#9).
- B Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on surveyor review of the clinical record, surveyor observations and interviews with the resident, resident's responsible party and the facility staff, it was determined that the facility failed to ensure residents' rights of choice. This finding was evident for 1 of 2 residents selected for the Choice review. (#108)
Fire safety inspections
16 fire safety citations on file: 2 on February 18, 2026, 13 on September 30, 2024, 1 on October 10, 2019.
Every fire safety citation16 citations
- F Conduct testing and exercise requirements.
- D Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- F Provide properly protected cooking facilities.
- F Inspect, test, and maintain automatic sprinkler systems.
- F To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F Have generator or other power source capable of supplying service within 10 seconds.
- E Establish roles under a Waiver declared by secretary.
- E Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- E Install proper backup exit lighting.
- E Have approved installation, maintenance and testing program for fire alarm systems.
- E Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- E Meet other general requirements that are deficient.
- D Keep aisles, corridors, and exits free of obstruction in case of emergency.
- D Properly select, install, inspect, or maintain portable fire extinguishes.
- D Install corridor and hallway doors that block smoke.
- C Meet requirements for the installation and maintenance of electrical systems.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Maryland | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.69 | 3.87 | 3.86 |
| Registered nurses | 1.01 | 0.84 | 0.69 |
| All nursing staff on weekends | 3.38 | 3.47 | 3.42 |
| Nurse aides | 1.89 | ||
| Licensed practical nurses | 0.78 | ||
| Nursing staff turnover (share who left in a year) | 16.7% | 40.2% | 45.8% |
| Registered nurse turnover | 17.6% | 38.7% | 42.9% |
| Administrators who left | 1 |
CMS expects 4.23 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.81 on weekdays and 3.38 on weekends, 11% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.63 in April to June 2025 to 3.69 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.69 | 1.01 | 3.81 | 3.38 | 0.0% | 0 of 90 | 156 |
| Oct to Dec 2025 | 3.85 | 1.06 | 3.98 | 3.52 | 0.0% | 0 of 92 | 149 |
| Jul to Sep 2025 | 3.79 | 1.04 | 3.94 | 3.39 | 0.0% | 0 of 92 | 146 |
| Apr to Jun 2025 | 3.63 | 0.96 | 3.79 | 3.20 | 0.0% | 0 of 91 | 148 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Maryland, Jan to Mar 2026 | 3.73 | 0.74 | 3.88 | 3.34 | 8.0% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Maryland | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 9.3 | 20.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.5 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.0 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.5 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.6 | 1.1 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 9.6 | 22.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.4 | 5.9 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 11.6 | 13.8 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 21.5 | 21.0 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 4.6 | 9.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.3 | 1.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.5 | 1.2 | 1.8 |
Owners and operators
Legal business name: POTOMAC OPERATOR LLC.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Md3 Operator Holdco LLC | 5% or greater direct ownership interest | Organization | 100% | 09/01/2023 |
| Green, Dov | 5% or greater indirect ownership interest | Individual | 43% | 09/01/2023 |
| Mermelstein, Boruch | 5% or greater indirect ownership interest | Individual | 45% | 09/01/2023 |
| Zager, Nachum | 5% or greater indirect ownership interest | Individual | 10% | 09/01/2023 |
| Poulsen, Cherilyn | W-2 managing employee | Individual | 09/01/2023 | |
| Zager, Nachum | Corporate officer | Individual | 09/01/2023 | |
| Zager, Nachum | Operational/managerial control | Individual | 09/01/2023 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- When is the care plan meeting, and can family attend it?Inspectors cited 5 problems in this area, most recently on February 18, 2026: "Ensure each resident receives an accurate assessment."
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 5 problems in this area, most recently on February 18, 2026: "Provide care and assistance to perform activities of daily living for any resident who is unable."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 4 problems in this area, most recently on February 18, 2026: "Ensure each resident’s drug regimen must be free from unnecessary drugs."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 4 problems in this area, most recently on September 30, 2024: "Reasonably accommodate the needs and preferences of each resident."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.38 hours per resident per day, below the Maryland average of 3.47.
- How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.
Other nursing homes nearby
- The Village at Rockville Rockville, 3.2 mi · 3 of 5 stars · 40 citations
- Potomac Valley Rehabilitation and Healthcare Rockville, 3.7 mi · 4 of 5 stars · 46 citations
- Montcare at Bethesda Bethesda, 3.7 mi · 5 of 5 stars · 28 citations
- Sterling Care Rockville Nursing Rockville, 4 mi · 4 of 5 stars · 42 citations
- Collingswood Rehabilitation and Healthcare Center Rockville, 4.1 mi · 2 of 5 stars · 74 citations
- Hebrew Home of Greater Washington Rockville, 4.4 mi · 5 of 5 stars · 31 citations
- Maplewood Park Place Bethesda, 4.6 mi · 5 of 5 stars · 5 citations
- Sterling Care Bethesda Bethesda, 4.7 mi · 3 of 5 stars · 37 citations
Maryland contacts for a concern about a nursing home
These are the official offices in Maryland. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Maryland Department of Health, Office of Health Care Quality, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Maryland Long-Term Care Ombudsman Program, Maryland Department of Aging, 800-243-3425. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Maryland Health Care Commission, Maryland Quality Reporting, Nursing Homes, where Maryland publishes its own records on licensed homes.
Common questions
- What is Montcare at Potomac's Medicare star rating?
- CMS rates Montcare at Potomac 5 out of 5 stars overall, with 4 for health inspections, 4 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Montcare at Potomac get at its last inspection?
- 8 health deficiencies at the standard inspection on February 18, 2026. The Maryland average is 17.
- Has Montcare at Potomac been fined?
- CMS lists no fines in the last three years.
- Does Montcare at Potomac accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Montcare at Potomac?
- CMS lists 7 owners and managers. Legal business name: POTOMAC OPERATOR LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.