MONTCARE AT POTOMAC
For profit - Limited Liability company
158 Beds
Independent
Data: November 2025
Trust Grade
90/100
#32 of 219 in MD
Photo by Montcare Potomac
Photo by Gruen Agency HCR - ManorCare
Photo by Gruen Agency HCR - ManorCare
1 / 10 photos
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Montcare at Potomac has an impressive Trust Grade of A, indicating excellent quality and high recommendations from families. Ranking #32 out of 219 facilities in Maryland places it in the top half, and it's #6 out of 34 in Montgomery County, which suggests that only a few local options are better. However, the facility's trend is concerning as it has worsened, increasing from 2 issues in 2019 to 11 in 2024, which may signal growing challenges. Staffing is a relative strength with a rating of 3 out of 5 stars and a low turnover rate of 18%, well below the state average, meaning staff members are likely to be familiar with residents' needs. Notably, there have been no fines recorded, but there were some specific incidents, including failure to notify family members of a resident's significant weight loss and improper administration of tube feeding, as well as a situation where a resident's call bell was out of reach, which could hinder timely assistance. While the facility excels in RN coverage, it is essential for families to weigh these strengths against the identified weaknesses.
- Trust Score
- A
- In Maryland
- #32/219
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 18% annual turnover. Excellent stability, 30 points below Maryland's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Maryland facilities.
- Skilled Nurses ✓ Good
- Each resident gets 57 minutes of Registered Nurse (RN) attention daily — more than average for Maryland. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 17 deficiencies on record. Higher than average. Multiple issues found across inspections.
90/100
Top 14%
No red flags
2 → 11 violations
★★★★★
5.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★★
5.0
Inspection Score
↔
Stable
2019: 2 issues
2024: 11 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (18%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (18%)
30 points below Maryland average of 48%
Facility shows strength in quality measures, staff retention, fire safety.
The Bad
No Significant Concerns Identified
This facility shows no red flags. Among Maryland's 100 nursing homes, only 1% achieve this.
The Ugly 17 deficiencies on record
Sept 2024
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based 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 ...
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Based 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.
The findings include:
On 9/19/24 at 9:52AM the surveyor observed Resident #28 laying in their bed, repeatedly gesturing and pointing to their head. When the surveyor attempted interview of the resident and inquired as to if they had a call bell device to ask for staff assistance, the resident was observed looking around their bed for the call bell device. At this time, the surveyor observed the call bell cord was plugged into the wall and was laying draped over top of the resident's wheelchair with the call device located behind a pillow situated on the wheelchair parked next to the resident's bed, not within reach of the resident. Upon further observation, the surveyor noted this was a tap style type of call bell device.
On 9/19/24 at 9:52AM the surveyor requested for a dual observation with Unit Manager #21, who accompanied the surveyor to the room of Resident #28 and observed and acknowledged the surveyor's concern. The surveyor observed Unit Manager #21 retrieve the call bell from the resident's wheelchair and secure it within reach of the resident. The resident was observed to have the ability to utilize/press the call bell. Upon interview of Unit Manager #21, they confirmed the call bell was not within reach of the resident, and confirmed their expectation was for residents to have their call bell within reach.
On 9/25/24 at 10:44AM upon review of the medical record, the surveyor observed the following intervention was listed on the careplan of Resident #28: Reinforce need to call for assistance.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based 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...
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Based 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.
The findings include:
On 9/20/2024 at 11:27 AM, review of the investigation report of Facility Reported Incident (FRI), MD00180957, revealed Resident #48's medication (28 tablets of Ativan 0.5 mg) that was supposedly delivered to the facility on 3/13/2022 on the 3-11 PM shift was not found even though staff found the controlled substance log that was to accompany the medication on their desk.
On 9/20/2024 at 11:56 PM, surveyor requested from the Director of Nursing (DON) the email/fax receipt of the initial and final (5-day) report of the FRI to the State Survey Agency (OHCQ).
On 9/20/2024 at 12:56 PM, surveyor received from DON the email receipt for the initial and final self-report to OHCQ. A review of the initial self-report revealed it was sent to OHCQ on 3/18/2022 at 6:48 PM. Thus, failing to meet the 24 hours reporting requirements for any allegation of misappropriation of resident property.
On 9/23/2024 at 12:38 PM in a follow up interview with DON, Surveyor reviewed the above FRI with her. DON was informed of surveyor's concerns regarding the actual date of the above incident (3/13/2022) and the date/time the initial report was sent to OHCQ (3/18/2022 at 6:48 PM). DON confirmed that the initial report did not meet the 24 hours reporting requirements for any allegation of misappropriation of resident property. However, she stated that the delay in reporting the above incident to the State Survey Agency was because they were waiting for pharmacy to review the medications delivered to the facility on that day (3/13/2022), and felt it was not necessary to do a self-report.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Based 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 identifi...
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Based 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.
The finding includes:
On 9/23/24 at 10:51 AM, the surveyor reviewed Resident #152's medical record for system-selected closed record review. The review revealed that a progress note written by a Licensed Practical Nurse (LPN #10) on 8/23/24 documented that Resident #152 was discharged home. Also, the facility had a form named My Transition Home, which was reported by LPN #10 about Resident #152's discharge. However, there was no documentation from the physician regarding Resident #152's discharge.
During an interview with the facility attending physician (Staff #4) on 9/24/24 at 10:07 AM, Staff #4 stated that they should document residents' discharge in the electronic medical records system within 30 days of discharge.
On 9/30/24 at 8:10 AM, the surveyor reviewed Resident #152's medical records again to verify whether the resident had discharge documentation from the physician within 30-day window. There was no record from the physician.
In an interview with the Director of Nursing (DON) on 9/30/24 at 11:30 AM, the surveyor shared concerns regarding residents' discharge records from a physician. She validated the concern.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based 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...
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Based 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.
The findings include:
1) During an initial screen of Resident #136 on 9/18/2024 at 9:18 AM, the resident stated that s/he was sent out to the hospital on 7/31/2024 for shortness of breath.
On 9/24/2024 at 12:15 PM a review of nurses' progress notes and change in condition documentation dated 8/1/2024 at 22:15 (10:15 PM) revealed Resident #136 was sent to the ER (emergency room) via 911 on 8/1/2024 for further evaluation and treatment of shortness of breath, weakness, and hypotension (low blood pressure).
On 9/24/2024 at 12:50 PM, surveyor requested and received from the VP of Clinical Services (Staff #23), copies of the change in condition form dated 8/1/2024. She stated that she could not locate any written notification of the reason for transfer to the hospital on 8/1/2024. However, she added that the reason for transfer to the hospital was noted in the change in condition form that was given to the surveyor.
On 9/25/2024 at 9:20 AM an interview was conducted with Licensed Practical Nurse (LPN #10).
Regarding written notification of reason for transfer to the hospital, LPN #10 stated that the reason for transfer was documented in the transfer form that was included in the paperwork (transfer packet) sent with the resident to the hospital. She stated that the residents were notified verbally of the reason for transfer to the hospital. LPN #10 added that family members/RP were notified of reason for transfer verbally in person if they were present in the building, and if they were not present, they were notified over the phone. She confirmed that she has not given in writing the reason for transfer to the hospital to any resident and/or their RP.
On 9/30/2024 at 11:35 AM, in an interview with the Director of Nursing (DON), surveyor shared concerns regarding written notification of resident and/or their RP of reason for transfer/discharge to the hospital. She did not provide any documentation that Resident #136 and/or their RP was notified in writing the reason for transfer to the hospital on 8/1/2024.
2) Review of the medical record for Resident #70 revealed the resident was transferred to an acute care facility on 8/19/2024. There was no documentation found in the medical record that the resident, and or the resident's responsible party was given written notice why the resident was transferred to the hospital in a language and manner that they understand.
On 9/20/24 at 11:27 AM the Administrator was made aware there was no documentation found in the medical why the resident was transferred to the hospital in a language and manner that they understand and confirmed the findings. The Administrator provided the surveyor a plan of correction to include the reason for transfer to an acute care facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined the facility failed to ensure a resident (Resident #81) received a recomm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
The findings include:
On 9/24/24 at 12:49PM the surveyor conducted a review of the medical record for Resident #81 which revealed the resident was discharged after hospitalization on 7/20/2023 and during their hospitalization the resident was seen by urology for a cystoscopy with right ureteral (tube that carries urine from the kidneys to the bladder) stent placement (small plastic tube inserted into the ureter to keep the urine pathway open). Review of the resident's hospital discharge summary revealed they needed to have a follow up outpatient appointment with urology after their hospital discharge, and further stated the ureteral stent was temporary and that the urologist office was to be called for scheduling of the outpatient ureteroscopy with laser lithotripsy.
Further review of subsequent hospitalization documentation for the resident revealed they had been hospitalized again on 1/18/24 with discharge diagnoses which included a complicated urinary tract infection. The hospital Discharge summary dated [DATE] revealed the following information: Urinary tract infection with gross hematuria, right ureteral stent extensively coiled upon itself within central collecting system and proximal ureter on CT (computed tomography: scan of the body), presented with uti suspected secondary to right ureteral stent causing gross hematuria and uti. Stent placed in July 2023; patient seemed to never follow up with urology. Documentation on the discharge summary documented the resident underwent a cystourethroscopy with laser (urologic procedure) on 1/23/24 and a right retained ureteral stent and right nephrolithiasis (solid material or stones formed in the urinary tract) was removed at that time.
On 9/24/24 at 12:49PM the surveyor requested documentation of all urology consults/appointments for the resident from July of 2023 through 1/18/24 from the Director of Nursing (DON).
Review of the medical record by the surveyor on 9/24/24 at 12:53PM of the Attending Physician #4's progress note dated 7/23/23 revealed the following information was documented: Obstructive uropathy: Notes: Patient status post cystoscopy with stent placement, patient was noted to have mild hematuria post stent, patient will need to follow up with urology, overall patient appears to be doing well and denies any dysuria or urinary frequency. No further documentation regarding scheduling or follow up with the urology specialist could be found by the surveyor in the medical record between the date of the first hospitalization and subsequent hospitalization. The surveyor additionally noted that the resident had documented urinary symptoms and treatments that further occurred at times leading up to the 1/18/24 hospitalization.
On 9/25/24 at 9:50AM the surveyor conducted an interview with Unit Manager #21 who observed the appointment calendar at that time and was unable to see any appointment having been scheduled for the urology follow up in question. During the interview, Unit Manager #21 asked for Unit Secretary #24 to check if any appointments had been made for the resident for the urology follow up appointment.
On 9/25/24 at 10:00AM the surveyor conducted an interview with the Assistant Director of Nursing #22 who reported to the surveyor that they could not recall if the resident had the appointment or not.
On 9/25/24 at 10:07AM the surveyor conducted an interview with the DON who confirmed there was no consult in the medical orders for the resident to see the urology specialist.
On 9/25/24 at 12:10PM the surveyor conducted an interview with Attending Physician #4 who reported to the surveyor several reasons as to why the appointment had not occurred, however, it was confirmed with Physician #4 that there was no documentation that could be found in the medical record that further discussed the recommended follow up urology appointment after their written progress note on 7/23/23.
On 9/26/24 at 11:41AM Unit Manager #21 confirmed with the surveyor that Unit Secretary #24 was unable to find any documentation regarding the facility having made any attempts to schedule the follow up urology appointment. At this time, the surveyor shared their concern with Unit Manager #21 and they acknowledged and confirmed understanding of the concern.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, it was determined that the facility failed to monitor and ev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
The findings include:
A review of Resident #145's medical record on 9/25/24 at 09:48 AM revealed that the resident was receiving tube feedings upon admission. Resident #145's body weight was documented as 80 pounds on 8/25/24 and 93.4 pounds on 9/13/24, which was a 16% weight gain within 19 days.
Further review of a progress note written by Staff # 25 (Dietitian-former) dated 9/13/24 at 2:33 PM revealed that 80 lbs (pound) is the recorded weight upon admission on [DATE] and is awaiting further weights to determine loss, gain or stability since admission. She also wrote that the resident was awaiting weekly weights 4X (times four).
On 9/25/24 at 11:10AM, an interview was conducted with the Registered Nurse (RN #8) about the process of obtaining weight and communicating the results. She stated that the Geriatric Nursing Assistants (GNAs) and nurses obtained residents' body weights. RN #8 explained that the weight was done by mechanical lift or scale, which would be documented monthly or weekly (if there was a specific order). When the GNA obtained weights, they were given to the nurse, who documented them in the electronic medical record (EMR). If there was a gain/loss of weight, the physician and dietitian were notified, and information was documented in the EMR.
On 9/25/24 at 11:32 AM, a review of the weight monitoring policy under the compliance guidelines stated that weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. under the documentation section of the policy, it states that the physician should be informed of a significant change in weight and may order nutritional interventions.
On 9/25/2024 at 12:31 PM, an interview with the Director of Nursing (DON) confirmed that resident #145's weight was 80 pounds upon admission, and the next weight was 93.4 pounds on 9/13/24. The DON further explained that parameters were in place to notify the physician if there was a weight gain or loss of 3-5 pounds.
On 9/25/24 at 1:10 PM, an interview with Staff #9 (Dietitian) stated that a resident's weight gain was a concern for the dietitian. She said the facility would review the weight formula with the physician when it was reported. The residents' conditions would also be reviewed, and interventions would be implemented. In addition, if a resident was underweight upon admission and weight gain was expected, it was still required to document their weight changes.
On 9/25/24 at 1:15 PM, upon further review of the Resident #145's medical record, there was no weight tracking found, and no documentation of communication between nursing, dietician, provider and resident's family member concerning the resident's weight gain.
On 9/30/24 at 11:30 AM, the surveyor shared the concern with the DON, and the DON validated the concern.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based 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 resid...
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Based 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.
The findings include:
Resident #97 was at the facility receiving short-term rehab. A record review conducted on 09/20/24 at 8:30 am revealed that resident #97 had a BIMS score of 0/15 on admission dated 08/26/24, indicating severe cognitive impairment. BIMS stands for Brief Interview for Mental Status, a standardized assessment tool to evaluate a patient's cognitive function. One of Resident #97's diagnoses was Chronic pain syndrome.
During an interview with the family member of Resident #97 on 9/20/24 at 09:13 AM, she/he stated that the resident has been in pain frequently despite getting pain medication.
During an interview with the Geriatric Nursing Assistant (GNA), staff # 27, on 09/30/24 at 09:47 AM, revealed that resident #97 was in pain when staff moved her/him during care and always grimaced with pain.
During an interview with the Licensed Practical Nurse (LPN), staff # 26 on 09/30/24 at 9:53 am, she/he stated that she/he reviews the pain medication parameters prior to administering pain medication as needed.
On 09/24/24 at 10:19 AM, a record review revealed that resident # 97's pain was not managed consistently. Resident #97 had an order written on 08/26/24 to document his/her pain score, stating Pain Score every shift on a scale of 0-10 0 = no pain 1-3 = mild pain 4-6 = moderate pain 7-10 = severe pain every shift for Pain. Medication orders (as needed) did not have parameters to correspond with pain scores:
Acetaminophen Oral Solution (Acetaminophen) Give 20.3 ml via PEG-Tube every 4 hours as needed for Pain
Morphine Sulfate Oral Solution 20 MG/5ML, Give 2.5 ml via PEG-Tube every 4 hours as needed for Pain.
oxyCODONE HCl Oral Tablet 5 MG, Give 5 mg via G-Tube every 4 hours as needed for Abdominal pain.
Further review of Resident #97's Medication Administration Record (MAR) revealed that the resident received:
On 09/23/24 at 8:47 AM Acetaminophen 20.3 ml via PEG tube for Pain Level 2,
On 09/10/24 at 4:49 PM oxyCODONE HCl Oral Tablet 5 mg via PEG tube for pain level 5,
On 09/14/24 at PM oxyCODONE HCl Oral Tablet 5 mg via PEG tube for pain level 6,
On 09/15/24 at 1:48 PM oxyCODONE HCl Oral Tablet 5 mg via PEG tube for pain level 6,
On 09/19/24 at 5:45 PM oxyCODONE HCl Oral Tablet 5 mg via PEG tube for pain level 5,
On 09/22/24 at 5 PM oxyCODONE HCl Oral Tablet 5 mg via PEG tube for pain level 3,
On 09/24/24 at 5:25 PM oxyCODONE HCl Oral Tablet 5 mg via PEG tube for pain level 3,
On 09/26/24 at 5 PM oxyCODONE HCl Oral Tablet 5 mg via PEG tube for pain level 6,
On 09/29/24 at 4:34 PM oxyCODONE HCl Oral Tablet 5 mg via PEG tube for pain level 4.
The surveyor reviewed and validated pain score information and medication parameters with the Director of Nursing (DON) on 09/30/24 at 11 am. DON stated that she/he would communicate with the physician to make the necessary changes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based 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....
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Based 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.
The findings include:
On 9/23/2024 at 11:54 AM, review of Resident #203's medical record revealed the resident was admitted to the facility in September 2024 with medical diagnosis that included but not limited to other specified disorders of muscle, infection and inflammatory reaction due to cardiac valve, pneumonia, type 2 diabetes mellitus, presence of cardiac pacemaker, and spondylosis lumbar region (osteoarthritis of the spine).
On 9/23/2024 at 12:04 PM, review of physician orders revealed an active order with a start date of 9/3/2024 for Tramadol HCL tablet 25 mg, give 25 mg by mouth every 4 hours as needed for Moderate Pain. Further review of the orders revealed active orders for: Pain Score every shift on a scale of 0-10, 0 = no pain 1-3 = mild pain 4-6 = moderate pain 7-10 = severe pain every shift for Pain dated 9/3/2024.
On 9/23/2024 at 12:29 PM, review of Resident #203's Medication Administration Record (MAR) for September 2024 was completed. Staff documentation revealed PRN Tramadol HCL 25 mg was given outside ordered parameters for Moderate pain level (4-6) on the following dates:
On 9/6/2024 - for pain score 0 at 0620 (6:20 AM) and
On 9/23/2024 - for pain score 2 at 1153 (11:53 AM).
On 9/23/2024 at 12:32 PM, Surveyor reviewed Resident #203's September 2024 MAR with the Director of Nursing (DON). She verified and confirmed that the 25 mg Tramadol was given inappropriately on the days/times when the resident's pain score was below 4 (ordered parameters not followed). DON stated that sometimes the residents may request a particular pain med, and the nurses would give it without paying attention to the orders. However, she indicated that she was going to review the nurses' notes and follow up with surveyor for explanation why the Tramadol was administered for pain score of 0 and 2 respectively.
On 9/25/2024 at 7:52 AM, in a follow up interview with the DON, she stated that she identified the nurses who administered the above Tramadol without following the ordered parameters and have started providing one-on-one education to them. DON further stated that they were working on harmonizing the pain scale throughout the facility and educating staff on following ordered parameters during PRN med administration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined facility staff failed to 1) safely store a resident's medication (Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
The findings include:
1) On 9/25/24 at 9:45 AM, during Medication Administration observation on the 2nd floor Unit for Resident #134 by Registered Nurse (RN # 8), surveyor observed a labeled plastic bag with a pill in it on the floor by the trash can close to the resident's bedside table. Surveyor showed RN #8 the plastic bag containing the pill, and she (RN #8) immediately picked it up. Upon exiting the room, surveyor requested to see what was in the plastic bag. RN #8 stated she threw it in the trash can in the resident's room. Surveyor asked RN #8 to go retrieve the bag. RN #8 went into the room and brought the plastic bag that she had picked from the floor and identified it as Atenolol 50 mg tab belonging to Resident #134's roommate (Resident #42). Surveyor verified that it was an unopened tab of Atenolol 50 mg (expiration date [DATE]) labeled for Resident #42.
On 9/25/2024 at 9:50 AM, surveyor shared her observation with the 2nd floor Unit Manager (UM # 12), who took the medication and stated he was going to follow up.
On 9/25/2024 at 12:31 PM, Surveyor reviewed with the Director of Nursing (DON) findings during med administration observation: Regarding the Atenolol found on the floor in the residents' room, DON stated that they took a picture of the plastic bag with the med in it and sent to their pharmacy (Geri Script) for verification. DON stated that the pharmacy did not recognize the plastic bag labeled with the Atenolol and stated that it was not from them. She added that the pharmacy did not send single dose /individual packet of any medication to the facility, they send blister packs that contain multiple doses. However, DON stated that Resident #42 was not currently on Atenolol and she (DON) was going to follow up with the resident's daughter to find out if they brought him/her any medications.
On 9/26/2024 at 8:23 AM, the Divisional Director of Quality Assurance (Staff #11) provided the surveyor with documentation from their pharmacy that the Atenolol 50 mg tablet was not supplied by them. She stated that the medication might have been in the resident's personal belongings because s/he came from the hospital. However, when asked how the medication ended up on the floor by the roommate's section of the room, Staff #11 stated that she did not know.
2) On 9/27/2024 at 11:40 AM, 1st Hallway medication cart (cart #22) was reviewed for medication storage and labeling in the presence of Registered Nurse, RN #19: Surveyor found in the bottom drawer of the med cart one bottle of Pro-Stat 15 g of Protein (floor stock) that expired on 7/26/2024. RN #19 verified and confirmed the finding and immediately removed the bottle from the cart.
On 9/27/2024 at 11:52 AM, observation was made of the treatment cart on the 1st floor unit in the presence of RN #15: The following expired and unsterile dressing supplies were found:
a) One (1) sealed/unopened bottle of Iodoform Packing Strip (1 inch) that expired on 6/4/2024. RN #15 verified the expiration date and confirmed that it was expired. She immediately removed it from the cart.
b) One (1) pack of Xeroform Petrolatum dressing 5x9 inch cut opened and the remaining dressing inside exposed. RN #15 confirmed that the dressing in the opened pack was no longer sterile and should not be in the treatment cart and immediately removed it.
On 9/30/2024 at 11:31 AM, the medication storage carts observations were reviewed with the Director of Nursing (DON). DON stated she was going to follow up.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview it was determined the facility staff failed to maintain the medical record in the m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
The findings include:
A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.
On 9/23/24 at 10:30A, the surveyor reviewed Resident #70's medical record. The review revealed that Resident was discharged to acute care on 8/19/24 and re-admitted to the facility on [DATE].
Resident #70's physician's orders on 4/20/2024 Cleanse stage 4 sacrum pressure injury with NSS, pat dry apply calcium alginate with silver and cover with foam every day.
Further review of Resident #70's Electronic Medical Record and Treatment Administration Record did not reveal wound care management on 8/1, 8/7, 8/12, 8/13 and 8/18/2024.
The Treatment Administration Record for the month of September did not reveal wound care management on 9/2, 9/3, 9/8, 9/10, 9/12, 9/18, and 9/20/2024.
On 9/23/24 at 11 AM, the Director of Nursing confirmed the findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined that the facility failed to provide education regarding th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
The findings include:
Pneumococcal vaccine helps prevent pneumococcal disease, which is any type of illness caused by streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends a pneumococcal vaccine for ages 65 years or older and adults 19 through [AGE] years old with certain medical conditions or risk factors. (Centers for Disease Control and Prevention- vaccines and preventable disease)
Flu is a contagious disease that spreads around the United States every year, usually between October and May. Anyone can get the flu, but it is more dangerous for some people. Infants and young children, people 65 years and older, pregnant people, and people with certain health conditions or a weakened immune system are at the greatest risk of flu complications. Influenza (Flu) vaccines can prevent influenza. (Centers for Disease Control and Prevention- vaccines and preventable disease)
On 9/26/24 at 11:49 AM, the surveyor reviewed the medical records of 5 randomly selected residents for immunization. The review revealed that Resident #29 had been residing at the facility since March 2020.
Further review of Resident #29's record revealed that the resident refused influenza vaccine in 2020. There was no documentation for the influenza vaccine in 2021. The documentation for the influenza vaccine in 2022 showed that the resident refused it. However, there was no evidence to support the resident receiving education on the vaccine's risks and/or benefits. There was no documentation for the influenza vaccine in 2023.
During an interview with the Infection Control Preventionist (Staff # 22) on 09/30/24 at 10:25 AM, she stated that the facility provided influenza education yearly to all residents, which should be documented in the Electronic Medical Record.
On 9/26/24 at 12:30 PM, the surveyor reviewed Resident #29's pneumococcal immunization record. The documentation for the pneumococcal vaccine for 2020 revealed that the resident refused. There was another documentation in March 2024 stating that Resident #29 refused the vaccine. However, there was no evidence to support the resident receiving education about the vaccine's risks and/or benefits.
During an interview with Staff #22 on 9/30/24 at 10:25 AM, she stated that the facility offered the pneumococcal vaccine and educated residents who had refused it quarterly and yearly about its risks and/or benefits.
On 9/30/24 at 11:30 AM, the surveyor shared the concern with the Director of Nursing (DON) regarding providing residents education about immunization risks and/or benefits. The DON validated the concern.
Oct 2019
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based 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...
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Based 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). The findings include:
On 10-07-19 at 12:14PM, and on 10-09-19 at 8:25AM, surveyor observed that resident #9 was using oxygen at 2 liters per minute via nasal cannula.
Review of the physician's orders revealed an order, written on 09-30-19 at 4:36PM, for oxygen 2 liters nasal cannula for 5 days to maintain oxygen saturation above 92%. This order was discontinued on 10-04-19
Review of the Treatment Administration Record revealed documentation that resident #9 received oxygen 2 liters via nasal canula from 09-30-19 through 10-05-19. Staff did not document the use of oxygen on 10-7-19 and 10-09-19.
In addition, the last nurse's progress notes, indicating that oxygen therapy was used, was dated 10-04-19.
On 10-10-19 at 9:25 AM, surveyor interview with LPN # 1 acknowledged that resident #9 was on oxygen and stated that the resident was on oxygen because their oxygen saturation was below 89%.
On 10-10-19 at 9:26 AM, surveyor interviewed the 2nd floor Unit Manager who acknowledged that resident #9 was on oxygen.
On 10-10-19 at 2:00 PM, surveyor interview with the Director of Nursing revealed no additional information.
As a standard of practice, according to the National Institute of Health, With the acknowledgement of oxygen as a drug, it should be prescribed cautiously and in critical cases should be tailored to individual needs. As healthcare professionals, we should not prescribe merely on verbal orders, instead should be prescribed with written orders with proper dosage, flow rate, and duration keeping in mind the complications that can arise on prolonged therapy. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3304228/ retrieved from US National Library of Medicine National Institutes of Health, 2011 Jan-Jun; 2(1): 10-14.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0561
(Tag F0561)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor review of the clinical record, surveyor observations and interviews with the resident, resident's responsible ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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) The findings include:
On 10-07-19 8:40 AM, surveyor interview with resident #108 revealed that he/she was not offered the opportunity to choose from the facility's menu what he/she prefers to eat. Resident #108 stated that I don't choose my food. I eat whatever is offered to me and sometimes I don't like what is offered so I don't eat it.
On 10-09-19, surveyor review of the clinical record for resident #108 revealed that the resident was admitted to the facility on [DATE]. Further review revealed that resident was alert and oriented and able to advocate for him/her self.
On 10-09-19 at 8:44 AM, surveyor interview with the food service manager revealed that all newly admitted residents were to be given a copy of the facility's weekly menu on admission. Alert and oriented residents circle the type of food they would like to eat based on the menu. If there is nothing on the menu that appeals to them, the residents can choose from an always available menu that is also provided to residents on admission and kept in their rooms.
On 10-09-19 at 9:00 AM, surveyor interview with resident #108's daughter revealed that the facility did not give the resident a menu upon admission.
On 10-09-19 at 9:15 AM, during interview with the food service manager, he stated that the dietician is the staff member responsible for providing menus to the residents during the initial nutritional assessment.
On 10-09-19 at 9:45 AM, surveyor interview with the dietician revealed she did notprovide the regular or always available menu to resident #108.
On 10-09-19 at 11:20 AM, surveyor interview with the Director of Nursing and the food service director revealed no new information.
Aug 2018
4 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, review of the clinical record, staff and family interviews, and review of the facility's weight ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, review of the clinical record, staff and family interviews, and review of the facility's weight management guideline, it was determined that the facility staff failed to promptly notify the appropriate parties of a significant change in condition for resident #265. This finding was evident for 1 of 41 residents selected for review during the survey. The findings include:
On 08-02-18 at approximately 11:00 AM, while sitting at the second floor nurses station, surveyor observed a family member for resident #265 approach the nurses station to inform the facility staff that he/she had called 911 to have his/her family member transferred to the emergency room for evaluation. The family member alleged the resident was emaciated, and that the facility staff did not notify him/her of resident #265's significant weight loss.
Review of the clinical record on 08-02-18 revealed resident #265 was admitted to the facility on [DATE] with diagnoses that included malnutrition and a history of weight loss. At the time of admission, the clinical record reflected an admission weight of 142 pounds for the resident.
Further review revealed on 07-23-18, that the facility staff had obtained a weight of 111.1 pounds for resident #265 (a loss of 30.9 pounds in the 11 days since the resident's admission). However, there was no evidence in the clinical record that the facility staff had obtained a reweigh to verify the significant weight loss, nor documented evidence that the facility's dietitian, attending physician, or legal guardian had been informed of the weight loss.
In addition, record review revealed weight results obtained on 07-30-18 of 110.6 pounds (a 31.4 pound/22.1% weight loss since resident #265's admission to the facility on [DATE]). A nutrition/weight progress note, dated
07-30-18 at 1:12 PM, revealed documentation of the notification to the attending physician and the resident's legal guardian. The dietitian also documented that the resident had been restarted on tube feedings of Ensure 1 can twice daily as of 07-29-18 to supplement meals. Then on 07-30-18, after discussion of the weight loss with the attending physician, the resident was placed on a tube feeding of Two Cal HN to run at 60 ml (milliliters)/hour for 10 hours a day.
Further record review revealed on 08-01-17 weight results for resident #265 of 121 pounds (up 11 pounds in 2 days). However, there was no documented evidence in the clinical record that a reweigh to verify the accuracy of the 121 pound weight had been obtained, nor that staff had notified the facility dietitian, attending physician nor legal guardian of the 11 pound gain.
On 08-02-18, upon surveyor intervention, a reweigh was obtained with a result of 115 pounds for resident #265, and the 121 pound weight was voided.
On 08-02-18, surveyor review of the care plan initiated on the date of admission for resident #265 revealed interventions that included facility staff were to review weights and notify physician and responsible party of significant weight change. In addition, review of the facility's weight management guideline revealed if the patient experiences a change of condition and develops signs and symptoms for weight change, several factors are considered by the interdisciplinary team, and that The physician and family are notified about changes in condition.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on surveyor review of the clinical record, interview with resident and facility staff, it was determined that the facility staff failed to follow physician orders for resident #99. This finding ...
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Based on surveyor review of the clinical record, interview with resident and facility staff, it was determined that the facility staff failed to follow physician orders for resident #99. This finding was evident for 1 of 4 residents selected for the Tube Feeding care area review. The findings include:
On 07-31-18 at 10:18AM, surveyor interview with resident #99 revealed concerns over the administration of the resident's tube feeding and water flushes that were too close together in times, or at times were administered late during the shifts. The tube feedings and the water flushes are administered via the resident's gastrostomy tube (GT).
A GT is a tube placed directly into the stomach through the abdomen and used to administer nutrition, fluids and medicines.
On 08-01-18, surveyor review of the clinical record for resident # 99 revealed on 06-28-18 the attending physician ordered Jevity 1.5 (2 cans) to be administered three times daily every 8 hours via the GT. In addition, on 06-28-18 the attending physician ordered 150 ml of water flushes via the GT to be administered four times daily every 6 hours.
However, review of the June 2018 and July 2018 electronic MAR (Medication Administration Record) revealed that facility staff administered the tube feedings to resident #99 at 9AM, 1PM and 5PM from 06-28-18 at 1PM until surveyor intervention on 08-01-18, and not every 8 hours as ordered by the physician.
Further review of the June and July 2018 electronic MAR revealed that staff administered the water flushes at 9AM, 1PM, 5PM and 10PM via resident #99's GT from 06-28-18 at 1PM until surveyor intervention on 08-01-18, and not every 6 hours as ordered by the physician.
On 08-01-18 at 4PM, surveyor interview with the Director of Nursing and the facility administrator revealed no additional information.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0730
(Tag F0730)
Minor procedural issue · This affected multiple residents
Based on review of employee records and facility staff interviews, it was determined that the facility failed to provide the minimum 12 hours of yearly in-service education to the facility's nurse aid...
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Based on review of employee records and facility staff interviews, it was determined that the facility failed to provide the minimum 12 hours of yearly in-service education to the facility's nurse aides. This was evident for 3 of 3 nurse aides (#1, #2, #3) selected for review during the survey. The findings include:
1. On 08-03-18, surveyor review of Geriatric Nursing Assistant (GNA) #1's employee record revealed that he/she received less than 12 hours of yearly in-service education. Interview on 08-03-18 at 11AM with the facility administrator and Director of Nursing (DON) revealed no new information.
2. On 08-03-18, surveyor review of GNA #2's employee record revealed that he/she received less than 12 hours of yearly in-service education. Interview on 08-03-18 at 11AM with the facility administrator and Director of Nursing (DON) revealed no new information .
3. On 08-03-18, surveyor review of GNA #3's employee record revealed that he/she received less than 12 hours of yearly in-service education. Interview on 08-03-18 at 11AM with the facility administrator and Director of Nursing (DON) revealed no new information.
MINOR
(B)
Minor Issue - procedural, no safety impact
Medical Records
(Tag F0842)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor review of the clinical record and interview with facility staff, it was determined that the facility staff fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor review of the clinical record and interview with facility staff, it was determined that the facility staff failed to ensure completed documentation in the clinical record for residents. This finding was evident for 2 of 41 residents selected for review. (#18, #99) The findings include:
1. On 08-03-18, surveyor review of the clinical record for resident #18 revealed a diagnosis of prostate cancer. The resident was seen by an oncologist on 03-09-18 for consultation related to the diagnosis. Review of the
03-19-18 oncology office visit documentation revealed problem with facility and getting resident to receive monthly [NAME] infusion medication, in which the oncologist believed might be beneficial for the resident's bone disease.
Further review of the clinical record revealed the attending physician for resident #18 documented an attempt to contact the oncologist on 05-18-18 to obtain clarification on the recommendation for the [NAME] and was informed that the oncologist would get back to him/her.
However, the physician's progress note, dated 06-29-18, had failed to address the recommendation for the [NAME] infusion, and any follow up conversation with the oncologist after 05-18-18. In addition, there was no documented evidence in the note for the need to follow up with the oncologist nor any further documentation regarding the recommendation for the [NAME].
On 07-31-18 at 2:40 PM, an interview with the Director of Nursing revealed no additional information.
After surveyor intervention, a physician's progress note, dated 08-01-18, documented have spoken with oncologist in the past month and we discussed [NAME] considered for bone reabsorption, however this medication has multiple side effects that include agitation, convulsion, confusion and bleeding. The attending physician also documented at this time decided that [NAME] is not indicated. Patient will follow up routinely with oncologist.
On 08-03-18 at 11:10 AM, interview of resident #18's attending physician revealed that the physician spoke with the consulting oncologist but had acknowledged that he/she had failed to document further communication Further interview revealed that the resident has a follow up appointment in September and the oncologist informed the attending physician that the [NAME] infusion will be reconsidered at that time.2. On 08-02-18, surveyor review of the clinical record revealed that, on 07-13-18, the attending physician ordered weights on Mondays, Wednesdays and Fridays for resident # 99. Further review revealed staff documentation on the July and August 2018 electronic MAR (Medication Administration Record) that the weights were completed on Mondays, Wednesdays and Fridays since 07-16-18.
However, review of resident #99's clinical record revealed weight results were only documented for 07-18, 30, and 08-01 and 02- 2018. Further record review revealed no evidence of staff documentation of the weight results for 07-16, 20, 23, 25 and 27-18, in the clinical record until surveyor intervention on 08-02-18.
On 08-02-18 at 1:39PM, surveyor interview with RN (Registered Nurse) #5 revealed that weights are recorded in the electronic record for residents after the weight is obtained. Further interview revealed that RN #5 had initialed that a weight for resident #99 was obtained as ordered. However, RN #5 had failed to document the results in the record. No additional information was provided.
On 08-02-18 at 1:45PM, surveyor interview with RN #4 revealed that the 07-13-18 order was electronically put in resident #99's electronic record to obtain weights on Mondays, Wednesdays and Fridays. However, an electronic entry for the weight results was not triggered that would have noted the actual weight results. No additional information was provided.
On 08-02-18 at 3:30PM, surveyor interview with the Director of Nursing and the facility administrator revealed no additional information.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Grade A (90/100). Above average facility, better than most options in Maryland.
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Maryland facilities.
- • 18% annual turnover. Excellent stability, 30 points below Maryland's 48% average. Staff who stay learn residents' needs.
Concerns
- • 17 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
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About This Facility
What is Montcare At Potomac's CMS Rating?
CMS assigns MONTCARE AT POTOMAC an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Maryland, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Montcare At Potomac Staffed?
CMS rates MONTCARE AT POTOMAC's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 18%, compared to the Maryland average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Montcare At Potomac?
State health inspectors documented 17 deficiencies at MONTCARE AT POTOMAC during 2018 to 2024. These included: 14 with potential for harm and 3 minor or isolated issues.
Who Owns and Operates Montcare At Potomac?
MONTCARE AT POTOMAC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 158 certified beds and approximately 148 residents (about 94% occupancy), it is a mid-sized facility located in POTOMAC, Maryland.
How Does Montcare At Potomac Compare to Other Maryland Nursing Homes?
Compared to the 100 nursing homes in Maryland, MONTCARE AT POTOMAC's overall rating (5 stars) is above the state average of 3.1, staff turnover (18%) is significantly lower than the state average of 46%, and health inspection rating (5 stars) is much above the national benchmark.
What Should Families Ask When Visiting Montcare At Potomac?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Montcare At Potomac Safe?
Based on CMS inspection data, MONTCARE AT POTOMAC has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Maryland. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Montcare At Potomac Stick Around?
Staff at MONTCARE AT POTOMAC tend to stick around. With a turnover rate of 18%, the facility is 28 percentage points below the Maryland average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 15%, meaning experienced RNs are available to handle complex medical needs.
Was Montcare At Potomac Ever Fined?
MONTCARE AT POTOMAC has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Montcare At Potomac on Any Federal Watch List?
MONTCARE AT POTOMAC is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.