9701 Medical Center Drive, Rockville, MD 20850 · Montgomery County · (301) 315-1900
154 certified beds, about 139 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1987
CMS Care Compare ratings, data as of September 1, 2026 · CCN 215164 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on May 8, 2026, inspectors cited 20 health deficiencies (the Maryland average is 17, the national average 9.2).
Of 90 health citations since January 2021, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $8,278 in the last three years; the largest was $8,278, and the latest is dated June 16, 2025.
Nurses and nurse aides worked 3.60 hours per resident per day, against 3.87 across Maryland and 3.86 nationally. Registered nurses accounted for 0.67 of those hours.
30.6% of nursing staff left within the year CMS measured (Maryland average 40.2%).
CMS links it to Lifeworks Rehab, an affiliated group of 64 nursing homes.
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.
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 90 health citations on file.
Inspectors wroteBased on reviews of a closed clinical record, all pertinent facility administrative records, and interviews with the facility staff, it was determined that the facility nursing staff failed to 1) follow the physician's specific pulse and blood pressure parameters before administering cardiac medications to residents, and 2) failed to document an associated blood pressure before administering the cardiac medication. This was evident for 1 (Resident #1) of 4 residents reviewed during a complaint survey.
Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (Resident #3) of 4 residents reviewed during a complaint survey.
Inspectors wroteBased on observations and interviews, it was determined that the facility failed to maintain food storage and food service equipment in a safe and sanitary manner to help prevent potential foodborne illness. This deficient practice was evident for 1 of 1 resident food storage refrigerator reviewed, and during the kitchen tour conducted during the annual survey.
Inspectors wroteBased on complaint investigation, record reviews, and interviews, it was determined that the facility staff failed to ensure a resident was able to exercise the rights to leave the facility against medical advice without interference. This deficient practice was evident for one (Resident # 154) resident reviewed for resident rights during the annual survey.
Inspectors wroteBased on observation, medical record review, and interviews it was determined the facility failed to document the interdisciplinary team assessed and deemed appropriate for a resident to self-administer medication. This was evidenced in 1 (#70) of 1 resident reviewed for self-administering medication during the survey.
Inspectors wroteBased on observation and interviews, it was determined that the facility failed to ensure a safe, clean, comfortable and homelike environment with adequate lighting. This was evident for 6 (200, 300, 608, 701, 805 and 908) out of 27 rooms observed during the initial tour and throughout the recertification survey.
Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to ensure residents receive written bed hold notice upon hospital transfer. This deficient practice was evident for 2 (Resident #126 and Resident # 1) of 4 resident's reviewed for discharge process during the annual survey.
Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to provide the resident and/or the resident's representative with a summary of the baseline care plan. This deficient practice was evident for 2 (Resident #1, Resident #23) of 5 residents reviewed for baseline care plans during the annual survey.
Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that the facility failed to hold care plan meetings composed of an interdisciplinary team after the completion of the Minimum Data Set assessment. This was evident for 3 (Resident #10, #11 and #55) of 3 residents reviewed for care planning during the survey. Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team.
Inspectors wroteBased on interviews and record review, it was determined that the facility failed to provide treatments to assure proper care was provided for residents with documented skin issues. This was evident in 2 (Resident #10 and Resident #83) out of 14 residents reviewed for skin integrity during the recertification and complaint surveys.
Inspectors wroteBased on review of medical records and interviews it was determined that the facility failed to adequately assist a dependent resident during Activity of Daily Living (ADL) cares. This was found evident for 1 (Resident #80) out of 6 residents reviewed for abuse.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interviews, observations, and record reviews, it was determined that the facility failed to ensure central line dressings were changed according to the physicians' orders. This deficient practice was evident for one (Resident #117) resident review for intravenous therapy during the annual survey. Intravenous (IV) therapy is the administration of parenteral fluids or medications through an IV catheter to treat a condition. A central line (also known as a central venous catheter) is a catheter (tube) that healthcare providers often place in a large vein in the neck, chest or groin.
Inspectors wroteBased on interview and record review it was determined that the facility failed to administer pain medications consistent with professional standards. This was found evident of 1 (Resident #5) out of 4 Residents reviewed for pain management during the survey.
Inspectors wroteBased on record review and interviews with staff, it was determined that the medical provider failed to review the total program of care for 2 (Resident #8 and #5) out of 55 residents reviewed during the survey.
Inspectors wroteBased on interview and observation, it was determined the facility failed to provide sufficient staff to respond to the call system promptly. This was found to be evident for 1 (#14) out of 2 residents observed for call system response.
Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to obtain, document and administer medications according to procedures that ensure accurate, safe dispensing of medications. This was evident for 4 residents (#57, #70, #98 and #141) out of 10 reviewed for medications.
Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure expired medications were removed from the medication storage room. This deficient practice was evident for one of two medication storage rooms reviewed during the annual survey.
Inspectors wroteBased on observations and interviews it was determined that the facility failed to accommodate a resident's intolerance by not providing alternative options with similar nutritional value. This was found evident in 1 (Resident #43) in 1 resident reviewed for food preferences.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility staff failed to ensure accurate documentation of treatments provided to residents and failed to ensure accurate documentation of resident's skin assessments. This deficient practice was evident for 2 (Resident #83 and Resident #117) of 2 residents reviewed for resident records during the annual survey.
Inspectors wroteBased on observations, and interviews, it was determined that the facility failed to maintain infection prevention and control practices including proper medication administration techniques and the appropriate use of cleaning equipment in a manner that minimized the potential spread of pathogens. This deficient practice was evident during 1 of 3 medication administration observations and for 2 of 2 equipment room reviewed during the annual survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation and interview with facility staff, it was determined that the facility failed to ensure proper airflow in the soiled laundry room. This was evident from the tour of the soiled laundry room conducted during the annual survey.
Inspectors wroteBased on facility policy review and interviews, it was determined that the facility failed to have a Medication Regiment Review policy in place with time frames to indicate when irregularities recommendations with urgent need should be acted upon. This was found evident of 1 of 3 pharmacy policies reviewed. Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the Inter Disciplinary Team (IDT), including the resident, their family, and/or resident representative.
Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to report to the State Agency Office of Health Care Quality (OHCQ) a resident's elopement. This was found to be evident for 1 (Resident #1) out of 1 Resident reviewed for elopement during the complaint survey.
Inspectors wroteBased on observation and interview, the facility failed to ensure proper securement of a suprapubic catheter for 1 (Resident #19) of 2 residents observed with a suprapubic catheter during the complaint survey, resulting in catheter dislodgement, urine saturation of the bed, and resident discomfort. The Findings Include: Review of facility policy, titled Nursing Care and Services dated 1/29/2024 documented, that the center will utilize Mosby's Textbook for Long-Term Care Assistants by Kostelnick and/or Clinical Nursing Skills & Techniques by [NAME], [NAME], and Ostendorff, as a reference for nursing services and skills not otherwise provided in the Policies and Procedures Manuals. Review of the medical record for Resident #19 revealed an admission date of 5/2/2022. [...]
Inspectors wroteBased on observation, interview, record review, and a review of facility policies, the facility failed to ensure staff followed an infection prevention can control program designed to provide a safe and sanitary environment for two (2) of two (2) residents (Resident # 18 and Resident # 19) observed for perineal care during the complaint survey .The Findings Include: Review of facility policy, titled Handwashing Requirements dated 2/6/2020 documented, All staff are trained in proper technique upon hire, annually, and PRN, and are monitored for proper handwashing practices. Employees will wash hands at appropriate times to reduce the risk of transmission and acquisition of infections. D. Gloves.3. Change gloves during patient care when moving from a contaminated body site to a clean body site.1) Review of the medical record for Resident #18 revealed an admission date of 11/21/2025. [...]
Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that only qualified staff provided residents with activities of daily living (ADL) care. This was evident for 1 (Resident #1) of 3 residents reviewed for having private duty aides during the complaint survey.
Inspectors wroteBased on observation, interview, record review, facility policy review, and review of manufacturer's guidelines for mechanical lifts and for mechanical lift slings, the facility failed to follow the guidelines for operation of the mechanical lift for 1 (Resident #2) of 2 residents observed that were transferred with a sling. The failure to follow the facility policy and guidelines supplied by the manufacturer contributed to Resident #2 sustaining a severely comminuted (a fracture of a bone into three or more pieces usually from high impact trauma or a fall from heights) fracture.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to assess a resident whose medication was left at bedside and who desired to self-administer medication for 1 (Resident #1) of 3 residents reviewed for medications.
Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure nonverbal and/or cognitively impaired residents were assessed during an abuse investigation for 1 of 2 abuse investigations reviewed.
Inspectors wroteBased on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure a medication error rate of less than 5 percent (%). There were 2 errors out of 30 opportunities, which resulted in a 6.66% medication error rate affecting 1 (Resident #16) of 7 residents observed during medication administration.
Inspectors wroteBased on record review and interview with staff it was determined that the facility staff failed to: 1) ensure the resident's person-centered care plan was reviewed and revised in response to current interventions to meet the respiratory needs and 2) failed to ensure residents were offered the opportunity to participate in the care planning process by holding annual and quarterly care plan meetings. This was evident for 9 (#25, #38, #42, #49, #52, #54, #74, #82, & #95) out of 10 residents records reviewed for care planning during the recertification survey.
Inspectors wroteBased on record review and interviews, it was determined that the facility staff failed to notify the state agency of allegations of abuse within the two-hour allotted timeframe. This deficient practice was evidenced in 6 (Resident #25, #41, #108, #113, #138, & #144) of 12 facility reported incidents reviewed for allegations of abuse during the recertification survey.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to develop a care plan to manage the resident's new medical diagnosis. This deficient practice was evident for 1 (#25) of 10 residents reviewed for comprehensive care plans during the survey.
Inspectors wroteBased on record review and interviews it was determined that the facility staff failed to adhere to professional nursing standards regarding implementing physician orders, medication administration times and documentation, and wound care orders/management and documentation. This deficient practice was evident in 8 (#25, #27, #82, #145, #79,) of 59 residents reviewed during the recertification survey.
Inspectors wroteBased on observations, record reviews, and interviews with staff, it was determined that the facility failed to ensure precautions were taken for residents' individual safety in need of supervision while smoking and failed to ensure smoking assessments were reviewed and revised due to a resident's current condition. This was evident for 4 (Resident #62, #63, #132, and #239) out of 15 residents reviewed for smoking.
Inspectors wroteBased on observations and interviews it was determined that the kitchen staff failed to store and label food to prevent potential foodborne illnesses, cover their hair to prevent food contamination, and failed to properly thaw food in the refrigerator. This deficient practice was discovered during the recertification survey.
Inspectors wroteBased on medical record review and interviews it was determined that the facility staff failed to 1) document a resident's personal belongings, 2) failed to maintain medical records in accordance with accepted professional standards and practices, and 3) failed to ensure residents' medical records were accurate and reflected their status. This deficient practice was evidenced in 9 (#41, #42, #58, #62, #63, #101, #102, #132, #239) of 29 resident record reviewed for accuracy of inventory during the recertification survey.
Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to ensure residents had access to their call bells to notify the staff for assistance when needed. This deficient practice was evidenced in 7 (#45, #50, #89, #122 #124, #131, & #148) of 138 residents observed without their call bell during the survey.
Inspectors wroteBased on observations and interviews, it was determined that facility staff failed to ensure a resident was dressed in their personal clothing as preferred. This deficient practice was evident for 1 (#287) of 138 residents observed for during the survey.
Inspectors wroteBased on record review and interviews it was determined that the facility staff failed to have a system in place to ensure that copies of the resident's Advanced Directives had been obtained and maintained in the resident's medical record; and failed to ensure that advance directives were discussed with residents and/or responsible representatives and proper information was provided. This was evident for 3 (#7, #27, & #101) out of 10 residents reviewed for Advanced Directives.
Inspectors wroteBased on record review and interview it was determined that the facility staff failed to ensure a resident received a skilled nursing facility beneficiary notice prior to discharge. This deficient practice was evidenced in 1 (#151) of 3 resident records for proper discharge documentation during the recertification survey.
Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to provide a homelike environment for the residents by failing to make repairs in the residents rooms. This deficient practice was discovered during observations of 2 of 3 units in the facility during the survey.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to develop and implement written policies and procedures for investigating and reporting allegations of abuse. This deficient practice was evident for 1 (#25) of 4 resident reviewed for abuse during the recertification survey.
Inspectors wroteBased on record review and interviews it was determined that the facility staff failed to complete a thorough investigation of alleged incidents of abuse and an injury of unknown origin. This deficient practice was evidenced in 4 (#25, #109, #138, & #144) of 12 facility reported investigations reviewed during the recertification survey.
Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to include the resident care plan goals with the required documentation during a transfer. This was evident for 1 (Resident #113) of 2 residents reviewed for hospitalization.
Inspectors wroteBased on record review and staff interview, it was determined that facility staff failed to provide written notification of transfer and to ensure the responsible representative is provided a copy. This was evident for 1 (Resident #113) of 2 residents reviewed for hospitalization.
Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to document the orientation and preparation of a resident upon transfer. This was evident for 1 (Resident #113) of 2 residents reviewed for hospitalization.
Inspectors wroteBased on interview and medical record review, it was determined the facility staff failed to notify the resident/resident representative in writing of the bed hold policy upon transfer. This was evident for 1 (Resident #113) of 2 residents reviewed for hospitalization.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure a resident's quarterly assessment was documented accurately on the Minimum Data Set (MDS). This deficient practice was evidenced for 1 (#25) resident out of in 4 residents reviewed for accurate MDS assessments during the survey.
Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility staff failed to ensure Preadmission Screening and Resident Review (PASARR) forms were completed correctly. This was evident in 3 (Resident #27, #79, and #101) of 4 residents reviewed for PASARR screening.
Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to assess residents quarterly for discharge planning goals. This deficient practice was evident for 2 (#52, #95) of 3 residents reviewed for discharge planning during the survey.
Inspectors wroteBased on medical record review and interviews it was determined that the facility staff failed to ensure residents were receiving showers regularly. This deficient practice was evidenced in 2 (Resident #20 & #58) of 27 residents who verbalized not receiving showers.
Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility staff failed to ensure a recommendation for diagnostic testing was completed, a resident was weighed monthly as ordered, and a resident representative was notified when a resident fell. This deficient practice was evident for 3 (#27, #42 #74) 27 residents reviewed during the recertification survey.
Inspectors wroteBased on record review and interview with resident and staff, it was determined that the facility failed to reorder a urinary sample for the purpose of diagnosing and treating which caused a delay in treatment for a resident with a Urinary Tract Infection (UTI). This was evident for 1 (Resident #18) out of 2 residents investigated for Urinary Catheters and UTI's during the survey.
Inspectors wroteBased on observation, record review, and interviews with resident and staff, it was determined that the facility staff failed to provide additional nourishment to a resident as ordered by the physician and failed to ensure a resident's diet was appropriate for their medical needs. This was evident for 2 (#98, #287) out of 5 residents reviewed for nutrition during the survey.
Inspectors wroteBased on observations, record review, and interviews it was determined that the facility staff failed to failed to ensure each resident has a sufficient supply of prescribed pain medication and ensure a resident's pain was addressed. This was evident for 2 (#54, #74) of 4 residents reviewed for pain management during the survey.
Inspectors wroteBased on observation, record review and interview with facility staff, it was determined that the facility failed to obtain informed consent prior to the initiation of a resident's bed rails. This was evident for 1 (Resident #113) of 1 resident reviewed for accident hazards.
Inspectors wroteBased on observation, record review, and interview with staff, it was determined that that facility failed to ensure a resident had orders in place to maintain immediate care needs of a resident with a Foley Catheter. This was evident for 1 resident (Resident #127) reviewed for indwelling catheters during the annual survey.
Inspectors wroteBased on record reviews, and interviews, it was determined that facility staff failed to ensure the physician notes reflected a review of the residents total care. This deficient practice was evident for 1 (#82) of 27 residents reviewed for physician services during the surveyor.
Inspectors wroteBased on observation, record review, and interview with staff, it was determined that the facility 1) failed to ensure that an account of all controlled drugs was complete and accurate. This was found to be evident for 1 out of 4 narcotic lock boxes located in the medication carts observed during the medication storage facility task; and 2) failed to timely identify and remove a discontinued controlled drug from the narcotic box for disposition. This was evident for 1 (Resident #102) out of 3 residents reviewed for pain management during the survey.
Inspectors wroteBased on medication administration observation, record review, and interviews with staff, it was determined that the licensed facility staff failed to ensure medication error rate of less than 5 percent. This was evident for 2 (Resident #96 and Resident #18) out of 5 residents observed during the medication administration task which resulted in an error rate of 11.54 percent.
Inspectors wroteBased on observation and interviews with staff, it was determined that the facility failed to ensure that all medications and medical treatment supplies were stored safely and labeled properly. This was evident for 1 room (Resident #98) out of 30 rooms observed and 1 medication cart out of 4 medication carts reviewed during the survey.
Inspectors wroteBased on observation, medical record review, and interviews it was determined that the facility staff failed to ensure that a resident who had poor dentition received dental services. This deficient practice was evidenced in 1 (#80) of 2 resident records reviewed for dental care during the recertification survey.
Inspectors wroteBased on observations and interviews, it was determined that facility staff failed to ensure availability of personal protective equipment (PPE) for enhanced barrier precautions (EBP) residents, and use appropriate infection control practice upon entering a resident's rooms. This was evident for 6 out of 18 rooms observed for PPE residents and 1 room observed for hand hygiene during the survey.
Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to make necessary repair in the kitchen. This deficient practice was discovered during the recertification survey.
Inspectors wroteBased on observation, record review and staff interview, it was determined the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails to identify areas of possible entrapment. This was evident for 1 (Resident #113) of 1 resident reviewed for accidents hazards.
Inspectors wroteBased on the review of a complaint, observations, interviews, and review of facility policy, it was determined that the facility failed to have a system in place to allow for visitor access to the facility after hours. This was evident for 1 (MD00180288) of 1 complaint reviewed for visitor access.
Inspectors wroteBased on the review of a complaint, medical record review and interview, it was determined that the facility failed to notify the resident/representative (RP) of a change in condition. This was evident for 1 (#51) of 10 residents reviewed for wound care.
Inspectors wroteBased on medical record review and interview, the facility staff failed to report to the Office of Health Care Quality (OHCQ) an injury of unknown origin as required. This was evident for 1 (#19) of 61 residents reviewed during a complaint survey.
Inspectors wroteBased on record review and interview it was determined that facility staff failed to ensure the Preadmission Screening and Resident Review (PASRR) was completed after the resident remained in the facility past the original 30 days and to accurately complete the PASSR on readmission for a resident to ensure the resident received appropriate services while in a long-term care setting. This was evident for 1 (#4) of 1 resident reviewed for PASRR.
Inspectors wroteBased on medical record review and interview with facility staff it was determined the facility staff failed to ensure the residents plan of care was updated when there was a change in the resident's pressure ulcer status and hold care plan meetings to include the interdisciplinary team, resident and resident's representative for a resident. This was evident for 1 (#8) and evident for 1 (#15) of 61 residents reviewed during the complaint survey.
Inspectors wroteBased on medical record review and interview with facility staff it was determined the facility staff failed to ensure preventative measures prescribed by the physician were clearly communicated to all staff responsible for implementing the interventions. This was evident for 1 (#8) of 61 residents reviewed during the complaint survey.
Inspectors wroteBased on medical record review and interview, the facility staff failed to administer medication as ordered by the physician. This was evident for 1 (#35) of 61 residents reviewed during a complaint survey.
Inspectors wroteBased on medical record review, observation, and interview, it was determined that the facility failed to 1) ensure a resident's pain medication was available as ordered by the physician and 2) ensure the pain medication orders had a clear indication for use, ensure a pain assessment was conducted, and to offer non-pharmacological pain management interventions. This was evident during the review of 1 (#41) of 4 residents reviewed for pain management and this was evident for 1 (#17) of 4 residents reviewed for pain management.
Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (#20) of 10 residents reviewed for accurate medical records during a revisit survey.
Inspectors wroteBased on surveyor observation, it was determined that the facility failed to have adequate ventilation to ensure good air quality circulation to keep all Nursing Units of the facility odor free. This was evident for 4 (200, 300, 400, and 500) of 5 nursing units.
Inspectors wroteBased on surveyor observation and facility staff interview it was determined that the facility failed to ensure nursing staff had the competency and skills to provide care to meet residents' needs. This finding was evident on all units.
Inspectors wroteBased on review of the clinical record and facilty staff interview, it was determined that the facility staff failed to review and revise residents' care plans in timely manner for 3 of 30 residents reviewed during the survey (Residents #51, #77, and #43).
Inspectors wroteBased on surveyor observation, review of the clinical record, and staff interviews, it was determined that facility failed to ensure staff were familiar with facility policies related to CPR and could confirm residents' code status in an emergency. This finding was evident in 2 of 4 residents selected for review of the advance directive care (Resident #230 and #91) On 01-12-2021 surveyor review of the clinical record revealed a MOLST (Maryland Orders for Life Sustaining Treatment) form for Resident #91 that documented the resident's code status as do not resuscitate (DNR). On 01-12-2021 at 2:00 PM surveyor interview with the interim Director of Nursing (DON) and Administrator revealed that since the facility has moved to an all electronic health record (EHR) the process for documenting code status and how staff determine code status in an emergency was as follows: [...]
Inspectors wroteBased on surveyor observations, review of clinical records, interviews with residents, family members and facility staff, it was determined that the facility staff failed to follow physicians' orders and to provide care in accordance with professional standards of practice. This finding was evident for 7 of 30 residents reviewed during the survey (Residents #31, #37, #56, #77, #82, #103, and #231).
Inspectors wroteBased on observation, clinical record review and staff interview, it was determined that the facility's staff failed to ensure feeding and fluids were administered accurately for 2 of 2 residents selected for a tube feeding review (Residents #129 and #230). 1. On 01-12-2021, record review revealed Resident #129 was NPO (nothing by mouth) and required therapeutic jejunostomy (J-tube feedings). A J -Tube feeding is feeding through a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine. Further record review of Resident #129's record revealed a physician's orders for tube feedings: Glucerna 1.7 at 70 ml/hr for 18 hrs for total volume of 1260 ml in 24 hour period; feeding pump is off from 12:00 PM to 6:00 PM. Surveyor observation revealed the following: [...]
Inspectors wroteBased on surveyor review of clinical records, resident and staff interviews it was determined that the facility failed to establish systems to accurately reconcile controlled medications using acceptable standards of practice and failed to provide medications as ordered by the prescriber for 2 of 30 residents reviewed during the survey (Resident #77 and #82).
Inspectors wroteBased on observations, medical record review, and staff interviews, it was determined that the facility's staff failed to implement proper infection control and prevention practices related to performing hand hygiene while providing assistance to multiple residents, and ensuring a resident's (Resident #31) implanted venous port (medical port) was secured in a manner to prevent infection. The facility's practice placed vulnerable residents at risk of contracting health care associated infections. This finding was evident in 2 of 4 units observed for proper infection control practices during the survey (Capital unit and Senate Unit).
Inspectors wroteBased on record review, resident and staff interviews, it was determined that the facility staff failed to notify residents' physician and family of a significant weight change. This finding was evident for 2 of 7 residents selected for review of the nutrition care area (Residents #43 and #51).
Inspectors wroteBased on medical record review and staff interview, it was determined that the facility's staff failed to develop and implement a base line care plan for a pressure ulcer. This finding was evident for 1 of 30 residents reviewed during the survey (Resident #37).
Inspectors wroteBased on resident record review and facility staff interview, it was determined that the facility staff failed to develop comprehensive patient centered care plans for 2 of 30 residents reviewed during the survey (Residents #51 and #130).
Inspectors wroteBased on surveyor observation, resident representative interview and staff interviews, it was determined that the facility's staff failed to provide assistance with activities of daily living to resident #108 who was dependent on staff for care. This was evident in 1 of 1 resident reviewed for ADL (activities of daily living) care area.
Inspectors wroteBased on surveyor observation, clinical record review and interviews with facility staff, it was determined that the facility failed to ensure residents were provided with an environment free of accident hazards. This was evident for 1 of 30 residents reviewed during the survey (#103).
Inspectors wroteBased on record review, resident interview and staff interviews, it was determined that the facility staff failed to address a significant weight loss for Resident #51. This finding was evident for 1 of 7 residents reviewed for adequate nutritional status during the survey.
Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility staff failed to maintain complete and accurate medical records for residents. This finding was evident for 2 of 30 residents reviewed during survey (Residents #77 and #231).
24 fire safety citations on file: 9 on May 8, 2026, 9 on March 13, 2025, 6 on January 15, 2021.
| Date | Penalty | Amount or length |
|---|---|---|
| June 16, 2025 | Fine | $8,278 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
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) | 3.60 | 3.87 | 3.86 |
| Registered nurses | 0.67 | 0.84 | 0.69 |
| All nursing staff on weekends | 3.29 | 3.47 | 3.42 |
| Nurse aides | 1.85 | ||
| Licensed practical nurses | 1.09 | ||
| Nursing staff turnover (share who left in a year) | 30.6% | 40.2% | 45.8% |
| Registered nurse turnover | 39.1% | 38.7% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.05 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
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 3.73 on weekdays and 3.29 on weekends, 12% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.49 in April to June 2025 to 3.60 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 | 3.60 | 0.67 | 3.73 | 3.29 | 0.2% | 0 of 90 | 139 |
| Oct to Dec 2025 | 3.66 | 0.61 | 3.79 | 3.31 | 0.0% | 0 of 92 | 129 |
| Jul to Sep 2025 | 3.38 | 0.57 | 3.51 | 3.03 | 0.0% | 0 of 92 | 132 |
| Apr to Jun 2025 | 3.49 | 0.62 | 3.64 | 3.11 | 0.0% | 0 of 91 | 132 |
| 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.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Maryland, all employers | |||
| CNAs (nursing assistants) | $20.79 | $18.46 to $22.00 | 27,720 |
| LPNs and LVNs | $35.89 | $31.40 to $38.30 | 9,560 |
| Registered nurses | $47.98 | $40.26 to $51.61 | 52,910 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
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 | 5.3 | 20.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.6 | 0.5 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.3 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.2 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.6 | 1.1 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 4.4 | 22.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.3 | 5.9 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 24.1 | 13.8 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 19.1 | 21.0 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 5.0 | 9.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.5 | 1.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.7 | 1.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Shady Grove Nursing and Rehabilitation Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (57.7% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
57.7% this home
Better than the national rate
US median of homes 51.5% · Maryland: 90 better, 29 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 322 eligible stays.
10.9% this home
No different from the national rate
US median of homes 10.7% · Maryland: 0 better, 41 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 343 eligible stays.
6.4% this home
No different from the national rate
US median of homes 7.1% · Maryland: 5 better, 6 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 235 eligible stays.
60.7% this home
Median of homes: Maryland61.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 140 residents counted.
0.4% this home
Median of homes: Maryland0.4% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 227 residents counted.
1.5% this home
Median of homes: Maryland2.4% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 227 residents counted.
94.6% this home
Median of homes: Maryland98.1% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 74 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: SHADY GROVE SNF LLC. CMS links this home to Lifeworks Rehab, a group of 64 nursing homes averaging 2.1 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Thunder Health Holdco LLC | 5% or greater direct ownership interest | Organization | 100% | 07/01/2018 |
| Rma Equity LLC | 5% or greater indirect ownership interest | Organization | 10% | 07/13/2023 |
| Birnbaum, Israel | 5% or greater indirect ownership interest | Individual | 37% | 05/01/2021 |
| Kohn, Avrohom | 5% or greater indirect ownership interest | Individual | 10% | 08/01/2018 |
| Birnbaum, Israel | W-2 managing employee | Individual | 08/01/2018 |
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.
Chosen from this home's own inspection record.
These are the official offices in Maryland. NursingHomeClear cannot take or act on complaints.