Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Montcare At Potomac during CMS and state inspections, most recent first.
Inaccurate MDS coding was found for two residents. One resident with vascular dementia and depression was receiving Abilify daily, but the MDS incorrectly showed no antipsychotic use in the prior 7 days. Another resident with severe cognitive impairment, documented elopement risk, and an alert bracelet was observed pacing, yet the MDS incorrectly coded the wander/elopement alarm as not used.
A resident had a nebulizer machine with unlabeled tubing observed on the nightstand, while the chart showed orders for weekly mask and tubing changes and PRN Ipratropium-Albuterol via nebulizer for SOB/emphysema. Review of the care plan found no evidence that a care plan had been initiated to address nebulizer treatment, and the DON acknowledged the finding.
Care plans were not revised to match current resident needs for three residents. One resident’s diuretic therapy had been discontinued, but the care plan still remained active. Two other residents had care plans that did not reflect observed nail care and personal hygiene needs, including long fingernails and dependence for personal hygiene, and the revisions were made only after surveyor intervention.
Failure to provide personal hygiene for dependent residents was identified when two residents with intact cognition and MDS-documented dependence for personal hygiene were observed with overgrown fingernails. One resident had long fingernails, and another reported repeated notifications to staff about untrimmed nails, which were observed extending about half an inch beyond the fingertips. A follow-up observation confirmed both residents still had overgrown fingernails, and a GNA stated staff were expected to provide ADL care, including nail trimming.
Respiratory care was not provided consistently with orders and facility protocol for three residents. An LPN and Unit Manager found oxygen tubing, humidifier bottles, nebulizer tubing, and suction catheter left unlabeled or undated, and one resident’s record lacked an order for weekly oxygen equipment changes even though staff said that was the facility practice. Another resident had oxygen in use with an undated nasal cannula and a humidifier bottle dated earlier than the review, while active orders later confirmed weekly nebulizer equipment changes for a third resident.
A resident with recent falls and facial bruising was found to still be receiving Gabapentin 100 mg BID even after the attending MD ordered it decreased to 100 mg QD following a pharmacy review. The Unit Mgr confirmed the order had not been implemented, and the DON was notified.
Unlabeled Opened Insulin Pens: During a medication cart observation, two opened insulin pens for a resident were found without the required opened date label. An RN unit manager confirmed the pens were opened and unlabeled, and the DON stated opened insulin pens are expected to be labeled with the opened date. Facility policy required insulin pens to be labeled with the resident name and date opened.
In the laundry room, an employee removed clean linen from a dryer and placed it in a bin, then picked up a blanket that had fallen on the floor and put it back into the bin with the clean linen. When questioned, the employee acknowledged the action was not appropriate, and the supervisor was informed of the observation.
A facility failed to report a possible misappropriation of a resident's medication within the required 24-hour timeframe to the OHCQ. The incident involved missing Ativan tablets, and the delay in reporting was due to waiting for a pharmacy review. The DON confirmed the report was sent five days late.
A resident was observed unable to reach their call bell device, which was found draped over their wheelchair and behind a pillow, out of reach. The Unit Manager confirmed the device was not accessible and acknowledged the expectation for it to be within reach. The resident's care plan included an intervention to reinforce the need to call for assistance.
A facility failed to ensure a physician documented a resident's discharge in the medical record. An LPN noted the discharge and completed a form, but no physician documentation was found. The attending physician acknowledged the requirement to document within 30 days, but this was not done. The DON confirmed the absence of documentation.
A resident did not receive a recommended follow-up urology appointment after hospitalization for a cystoscopy with stent placement. The hospital discharge summary indicated the need for this follow-up, but no documentation was found in the medical record to show that the appointment was scheduled. The resident was later hospitalized again with a complicated UTI, suspected to be related to the stent. Facility staff confirmed the absence of any scheduled follow-up appointments.
A resident experienced a significant weight gain of 16% over 19 days, increasing from 80 to 93.4 pounds, without proper monitoring or physician notification. Despite facility policy requiring communication for significant weight changes, there was no documentation of communication between nursing staff, the dietitian, the physician, or the resident's family. The DON confirmed the oversight, acknowledging the facility's failure to adhere to its weight monitoring parameters.
A resident with chronic pain syndrome and severe cognitive impairment experienced inconsistent pain management at the facility. Despite orders to document pain scores every shift, pain medication was administered without clear parameters corresponding to these scores. Interviews and record reviews revealed frequent pain episodes and grimacing during care, highlighting the facility's failure to manage the resident's pain effectively.
A resident received unnecessary PRN pain medication when Tramadol was administered outside the prescribed parameters for moderate pain. The medication was given for pain scores of 0 and 2, contrary to the physician's order for moderate pain (score 4-6). The DON confirmed the inappropriate administration and noted that nurses sometimes gave medication based on resident requests without following orders.
A survey revealed deficiencies in medication storage and disposal of expired supplies in an LTC facility. A resident's medication was found on the floor, and expired medications and unsterile dressing supplies were discovered in medication and treatment carts.
A facility failed to document education on the benefits and side effects of influenza and pneumococcal vaccines for a resident who repeatedly refused them. Despite claims of annual and quarterly educational efforts by staff, no evidence was found in the resident's medical records. The DON acknowledged the deficiency when informed by the surveyor.
The facility failed to provide written notification to two residents and their representatives regarding the reason for their transfer to a hospital. One resident was sent to the ER for shortness of breath, weakness, and hypotension, while another was transferred to an acute care facility. In both cases, the reasons for transfer were communicated verbally but not documented in writing, as confirmed by staff and the Administrator.
A resident with a stage 4 sacrum pressure injury had incomplete medical records regarding wound care management. Despite physician's orders for daily care, documentation was missing on several dates in August and September. The DON confirmed these findings during a survey.
Inaccurate MDS Coding for Antipsychotic Use and Wander/Elopement Alarm Status
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents, including coding related to antipsychotic medication use and wander/elopement alarm status. Resident #108 had diagnoses of vascular dementia and depression. Review of quarterly MDS assessments with ARDs of 09/30/25 and 12/30/25 showed Section N0415 was coded as not receiving an antipsychotic medication in the last 7 days, even though the resident had a physician order dated 03/19/25 for Aripiprazole (Abilify) daily at bedtime and the MAR showed the medication had been administered daily since that date. The MDS Coordinator reviewed the record and confirmed the medication was an antipsychotic and that the MDSs were inaccurately coded. Resident #154 was observed pacing in the hallways and was confirmed by the RN/UM to be at risk for elopement and wearing an alert bracelet. The resident had a BIMS score of 4.0 indicating severe cognitive impairment, a Quarterly Risk Evaluation confirming elopement risk, a physician order for an alert bracelet with function checks every shift, and a care plan identifying the resident as an elopement risk/wanderer with a history of attempts to leave the facility unattended and removing the bracelet. However, the Annual MDS with ARD 10/14/25 coded Section P0200, item E (Wander/elopement alarm) as not used, despite staff verification that it should have been coded as used daily.
Incomplete Care Plan for Nebulizer Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for the use of a nebulizer for Resident #1. During the initial tour, a nebulizer machine with unlabeled tubing was observed on the resident’s nightstand. Review of the active physician orders showed orders for nebulizer mask and tubing changes weekly on night shift, as well as an order for Ipratropium-Albuterol inhalation solution to be given via nebulizer every 6 hours as needed for shortness of breath/emphysema. However, review of the care plan found no evidence that a care plan had been initiated to address nebulizer treatment. The DON confirmed that care plans were generated upon admission and updated by the Unit Manager or MDS Coordinator and acknowledged the survey findings and concerns.
Care plans were not updated to reflect residents’ current medication and ADL needs
Penalty
Summary
The facility failed to review and revise care plans to match residents’ current needs for 3 of 41 residents reviewed during the recertification survey. One resident was prescribed Triamterene-HCTZ for hypertension starting on 10/17/24 and received it until it was discontinued on 12/24/24, but the active care plan still addressed diuretic therapy and was not revised to reflect that the medication had been stopped. During interview, the Unit Manager confirmed the medication had been discontinued while the related care plan remained active, and the surveyor observed that the care plan was resolved only after surveyor intervention. Two other residents had care plans that did not reflect their current ADL needs related to nail care and personal hygiene. One resident was observed with long fingernails and had an MDS showing dependence for personal hygiene, while another resident expressed frustration about untrimmed fingernails and was observed with fingernails extending about half an inch beyond the fingertips; that resident’s MDS also showed impairment in upper and lower extremities and dependence for personal hygiene. Their care plans were revised only after surveyor intervention to include resistance to care, encouragement for ADL care, and nail care needs.
Failure to Provide Personal Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide necessary personal hygiene to dependent residents, as shown by two residents who were reviewed for ADLs during the recertification survey. Resident #111 was observed with long fingernails and had a BIMS score of 15, indicating intact cognition. The resident’s quarterly MDS showed no impairment in range of motion but identified the resident as dependent for personal hygiene, meaning staff were responsible for completing the activity. Resident #91 also had overgrown fingernails, extending approximately half an inch beyond the fingertips, and expressed frustration that staff had been notified multiple times about the issue. This resident also had a BIMS score of 15 and a quarterly MDS showing impairment in the upper and lower extremities with a functional status of dependent for personal hygiene. A follow-up observation confirmed that both residents still had overgrown fingernails, and a GNA stated that staff were expected to provide ADL care, including nail trimming, and notify the assigned nurse if a resident refused.
Respiratory equipment was left unlabeled and orders were incomplete for oxygen and nebulizer care
Penalty
Summary
The facility failed to provide respiratory care services consistent with professional standards for three residents reviewed for respiratory care. Resident #28 was observed receiving oxygen at 2 liters per minute via nasal cannula, but the oxygen tubing and humidifier bottle were not labeled to show when they had been changed. The resident’s record included orders for continuous oxygen at 2 liters per minute and for oxygen tubing, respiratory bag, and humidified water to be changed and dated weekly, yet staff confirmed the tubing and humidifier bottle in the room were unlabeled and could not state when they had been changed. Resident #4 was observed in bed using oxygen at 2 liters per minute via nasal cannula, with a humidifier bottle dated 02/01/26 and an undated nasal cannula. The resident’s record showed an order for oxygen as needed for pulse oximetry below 92%, but there was no order in the clinical record for changing the oxygen tubing and humidifier bottle at the time of review. Staff stated it was the facility practice to change and document these items weekly in the TAR, and the Unit Manager confirmed the order was missing from the record. Resident #1 was observed with unlabeled nebulizer machine tubing and suction catheter on the nightstand, and the active physician orders later confirmed nebulizer mask and tubing were to be changed weekly, while the facility’s nebulizer policy also required weekly tubing changes.
Physician’s Gabapentin Order Not Implemented
Penalty
Summary
The facility failed to ensure a resident received medication according to the physician’s orders. Resident #31 was observed sitting in a wheelchair at the nurse’s station with a bandage over the left eye and bluish discoloration with swelling on the face, and the resident stated, “I fell.” The clinical record showed the resident had fallen on one date and again on 02/08/26, after which the resident was transferred to the Emergency Room. The record also showed that the facility requested a pharmacy review because of the resident’s falls. On 02/09/26, the pharmacy consultant recommended decreasing Gabapentin. The resident had been receiving Gabapentin 100 mg twice daily since 01/11/26. On 02/11/26, the attending physician entered an order to decrease Gabapentin to 100 mg once daily, but the facility continued administering Gabapentin 100 mg twice daily. The Unit Manager reviewed the record and confirmed the order had not been implemented, and the DON was notified of the concern.
Unlabeled Opened Insulin Pens
Penalty
Summary
The facility failed to ensure opened insulin pens were labeled with the date opened in accordance with facility policy. During observation of a medication cart on the Medbridge Unit, two opened insulin pens for Resident #48 were found stored in the top drawer without an opened date documented on either pen. RN Unit Manager #6 confirmed that both pens were opened and did not have an opened date label, and the DON stated that opened insulin pens are expected to be labeled with the opened date. Review of the facility policy titled Insulin Pen, revised 1/31/24, showed that insulin pens must be labeled with the resident name and the date opened, and that if the label is missing, the pen will not be used and a new pen must be ordered.
Infection Control Lapse in Laundry Room
Penalty
Summary
The facility failed to ensure appropriate infection prevention and control practices were followed in the laundry room. During observation, Staff #12 was seen removing clean linen from a dryer and placing it into a bin, and when a cream-colored blanket fell onto the floor, the staff member picked it up and placed it into the bin with the other clean linen. When the surveyor raised concern, Staff #12 acknowledged, "I am sorry, I should not do that." Supervisor Staff #13 later arrived, was informed of the finding, and Staff #12 confirmed the observation in the supervisor's presence.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility staff failed to report a possible misappropriation of resident property within the required 24-hour timeframe to the regulatory agency, the Office of Health Care Quality (OHCQ). This deficiency was identified during a recertification/complaint survey for one resident among those reviewed for abuse. Specifically, the incident involved the disappearance of 28 tablets of Ativan 0.5 mg, which were supposed to be delivered to the facility. Although the controlled substance log was found on the staff's desk, the medication itself was missing. The Director of Nursing (DON) confirmed that the initial report of the incident was sent to OHCQ five days after the incident occurred, thus failing to meet the 24-hour reporting requirement. The delay was attributed to the facility waiting for the pharmacy to review the medications delivered on the day of the incident. The DON acknowledged the reporting delay but believed it was unnecessary to self-report while awaiting the pharmacy's review.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call bell device was within reach of a resident, leading to a deficiency. During an observation, a surveyor noted that a resident was lying in bed and gesturing, seemingly trying to communicate a need for assistance. Upon inquiry, the resident was observed searching for the call bell device, which was found to be plugged into the wall and draped over the resident's wheelchair, with the call device itself located behind a pillow on the wheelchair, out of the resident's reach. The Unit Manager confirmed the call bell was not accessible to the resident and acknowledged that the expectation was for residents to have their call bell within reach. The resident's care plan included an intervention to reinforce the need to call for assistance, highlighting the importance of having the call bell accessible.
Physician Discharge Documentation Deficiency
Penalty
Summary
The facility failed to ensure that a physician documented a resident's discharge in the medical record, as required. This deficiency was identified during a recertification/complaint survey for a resident who was discharged home. A progress note written by an LPN indicated the discharge, and a form titled 'My Transition Home' was completed by the LPN regarding the discharge. However, there was no documentation from the physician in the resident's medical record. The attending physician acknowledged that they should document discharges within 30 days, but upon review, no such documentation was found within the required timeframe. The Director of Nursing confirmed the absence of the physician's discharge documentation.
Failure to Schedule Follow-Up Urology Appointment
Penalty
Summary
The facility failed to ensure a resident received a recommended specialist follow-up appointment after hospitalization. The resident was discharged after a hospital stay where they underwent a cystoscopy with right ureteral stent placement. The hospital discharge summary indicated the need for a follow-up outpatient appointment with urology, as the stent was temporary and required further procedures. However, there was no documentation in the medical record indicating that the follow-up appointment was scheduled or attended. The deficiency was identified during a recertification/complaint survey, where it was found that the resident had been hospitalized again with a complicated urinary tract infection, which was suspected to be secondary to the ureteral stent. Interviews with facility staff, including the Unit Manager, Assistant Director of Nursing, and the Director of Nursing, confirmed the absence of any scheduled urology follow-up appointments. The attending physician acknowledged the lack of documentation regarding the recommended follow-up, and the facility staff could not provide evidence of attempts to schedule the necessary appointment.
Failure to Monitor and Communicate Significant Weight Gain
Penalty
Summary
The facility failed to adequately monitor and evaluate a resident's significant weight gain and did not notify the physician as required. A resident, who was receiving tube feedings upon admission, experienced a 16% weight gain over 19 days, increasing from 80 pounds to 93.4 pounds. Despite the facility's policy requiring physician notification for significant weight changes, there was no documentation of communication between nursing staff, the dietitian, the physician, or the resident's family regarding this weight gain. Interviews with staff revealed that weights were typically obtained by Geriatric Nursing Assistants and nurses, and significant changes were supposed to be communicated to the physician and dietitian. However, in this case, the process was not followed. The Director of Nursing confirmed the weight gain and acknowledged that the facility had parameters in place to notify the physician for weight changes of 3-5 pounds, which were not adhered to in this instance. The lack of weight tracking and communication contributed to the deficiency identified during the survey.
Inconsistent Pain Management for Resident with Chronic Pain Syndrome
Penalty
Summary
The facility failed to consistently evaluate and manage the pain of a resident receiving short-term rehabilitation, who was diagnosed with chronic pain syndrome and had severe cognitive impairment as indicated by a BIMS score of 0/15. Despite having an order to document pain scores every shift, the resident's pain management was inconsistent. Interviews with the resident's family member and staff revealed that the resident frequently experienced pain, grimacing during care, and that pain medication was administered without clear parameters corresponding to the documented pain scores. The resident's Medication Administration Record showed multiple instances where pain medication was given, but the administration did not align with the pain scores recorded. For example, oxyCODONE was administered for pain levels ranging from 3 to 6, but there were no specific guidelines for medication administration based on these scores. This inconsistency in pain management was confirmed during a review with the Director of Nursing, who acknowledged the lack of appropriate medication parameters corresponding to the resident's pain scores.
Inappropriate Administration of PRN Pain Medication
Penalty
Summary
The facility staff failed to adhere to physician orders by administering PRN pain medication outside the prescribed parameters, resulting in the resident receiving unnecessary medication. This deficiency was identified during a recertification/complaint survey for one of the five residents reviewed for unnecessary medications. The resident involved was admitted to the facility with multiple medical diagnoses, including disorders of muscle, infection due to cardiac valve, pneumonia, type 2 diabetes mellitus, presence of a cardiac pacemaker, and spondylosis lumbar region. The physician's order specified Tramadol HCL 25 mg to be given every 4 hours as needed for moderate pain, defined as a pain score of 4-6 on a scale of 0-10. Upon reviewing the resident's Medication Administration Record (MAR) for September 2024, it was found that Tramadol was administered on two occasions when the resident's pain score was below the prescribed threshold. Specifically, the medication was given for a pain score of 0 and 2, which did not meet the criteria for moderate pain as per the physician's order. The Director of Nursing confirmed the inappropriate administration of Tramadol and acknowledged that nurses sometimes administered medication based on resident requests without adhering to the prescribed parameters.
Medication Storage and Expired Supplies Deficiency
Penalty
Summary
During a recertification and complaint survey, it was observed that the facility staff failed to safely store a resident's medication and dispose of expired medications and dressing supplies. On the 2nd floor unit, a surveyor found a labeled plastic bag containing an Atenolol 50 mg tablet on the floor near a resident's bedside table. The medication was identified as belonging to the roommate of the resident in the room, although the Director of Nursing later confirmed that the resident was not currently prescribed Atenolol. The pharmacy associated with the facility did not recognize the packaging, suggesting it may have been brought in from the hospital with the resident's personal belongings. Additionally, on the 1st floor unit, expired medications and unsterile dressing supplies were found in the medication and treatment carts. A bottle of Pro-Stat protein supplement was found to be expired, and expired Iodoform Packing Strip and opened, unsterile Xeroform Petrolatum dressing were discovered in the treatment cart. These findings were confirmed by the registered nurses present during the observations, who immediately removed the expired and unsterile items from the carts.
Deficiency in Vaccine Education Documentation
Penalty
Summary
The facility failed to provide education regarding the benefits and potential side effects of the influenza and pneumococcal vaccines to Resident #29, as evidenced during a recertification/complaint survey. The medical record review revealed that Resident #29, who had been residing at the facility since March 2020, refused the influenza vaccine in 2020 and 2022, with no documentation for 2021 and 2023. There was no evidence in the resident's records to support that education on the vaccine's risks and benefits was provided. Similarly, the pneumococcal vaccine records showed refusals in 2020 and March 2024, again without documentation of educational efforts. Interviews with the Infection Control Preventionist (Staff #22) indicated that the facility claimed to provide annual influenza education and quarterly and yearly education for the pneumococcal vaccine to residents who refused. However, this was not documented in the Electronic Medical Record for Resident #29. The Director of Nursing (DON) acknowledged the concern when it was shared by the surveyor, validating the deficiency in providing necessary education to the resident.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reason for transfer or discharge to a hospital. This deficiency was identified during a recertification/complaint survey for two residents who were hospitalized. Resident #136 was sent to the emergency room on 8/1/2024 for shortness of breath, weakness, and hypotension. Although the reason for transfer was documented in the change in condition form and verbally communicated to the resident and their representative, there was no written notification provided. The Licensed Practical Nurse confirmed that the reason for transfer was communicated verbally but not in writing. Similarly, Resident #70 was transferred to an acute care facility on 8/19/2024, and there was no documentation in the medical record indicating that the resident or their responsible party received written notice of the reason for the transfer. The Administrator acknowledged the absence of written documentation and confirmed the findings during the survey. The lack of written notification for both residents constitutes a failure to comply with regulatory requirements for resident transfer and discharge notifications.
Incomplete Medical Record for Wound Care Management
Penalty
Summary
The facility staff failed to maintain a complete and accurate medical record for a resident, as identified during a recertification/complaint survey. The resident, who had a stage 4 sacrum pressure injury, was discharged to acute care and later readmitted to the facility. Physician's orders dated April 20, 2024, specified daily wound care management for the pressure injury. However, the Electronic Medical Record and Treatment Administration Record lacked documentation of wound care management on several specified dates in August and September 2024. The Director of Nursing confirmed these findings during the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Potomac
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Village At Rockville | 3.2 mi | ★★★★★ | 25 | 0 |
| Potomac Valley Rehabilitation And Healthcare | 3.7 mi | ★★★★★ | 3 | 0 |
| Montcare At Bethesda | 3.7 mi | ★★★★★ | 14 | 0 |
| Sterling Care Rockville Nursing | 4 mi | ★★★★★ | 8 | 0 |
| Collingswood Rehabilitation And Healthcare Center | 4.1 mi | ★★★★★ | 18 | 0 |
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