Montcare at Wheaton
11901 Georgia Avenue, Wheaton, MD 20902 · Montgomery County · 94 certified beds · avg 89 residents/day · certified since Jun 13, 1967
2/5
Health inspection rating (on-site)
0
Serious findings on record
$0
Fines, last 3 years
3.45
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (58)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 11, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit. · from a complaint |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · from a complaint |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not give residents the required written notice of their rights, the facility's rules, the services offered, and what those services cost. · from a complaint |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · from a complaint |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. · from a complaint |
| Sep 27, 2019 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Sep 27, 2019 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Sep 27, 2019 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Sep 27, 2019 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Sep 27, 2019 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Sep 27, 2019 | D · Potential for harm, one-off | The facility admitted a resident without a doctor's order, or did not make sure each resident stayed under a doctor's ongoing care. |
| Sep 27, 2019 | C · Minimal risk, facility-wide | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Aug 17, 2018 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Aug 17, 2018 | E · Potential for harm, repeated | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Aug 17, 2018 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Aug 17, 2018 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Aug 17, 2018 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Aug 17, 2018 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 17, 2018 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Aug 17, 2018 | D · Potential for harm, one-off | The facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit. |
| Aug 17, 2018 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Aug 17, 2018 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 17, 2018 | B · Minimal risk, repeated | The facility did not honor a resident's right to choose their own attending doctor. Residents get to decide which physician oversees their care. |
| Aug 17, 2018 | B · Minimal risk, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Aug 17, 2018 | B · Minimal risk, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 17, 2018 | B · Minimal risk, repeated | The facility did not dispose of garbage and refuse properly. |
| Aug 17, 2018 | B · Minimal risk, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Aug 17, 2018 | B · Minimal risk, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (7 → 30).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2018 | 16 | 0 | E |
| 2019 | 7 | 0 | E |
| 2024 | 35 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Maryland avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.45 | 3.83 | 3.95 | bottom 46% in Maryland; bottom 34% in the U.S. |
| Registered Nurse hours | 0.73 | 0.83 | 0.69 | top 44% in Maryland; top 34% in the U.S. |
| Weekend total nurse staffing | 3.05 | 3.43 | 3.50 | bottom 40% in Maryland; bottom 34% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.47 | 0.63 | 0.48 | bottom 45% in Maryland; top 36% in the U.S. |
| Total nursing staff turnover (%) | 35.1 | 40.2 | 45.8 | top 33% in Maryland; top 24% in the U.S. |
| RN turnover (%) | 52.0 | 38.7 | 42.9 | bottom 22% in Maryland; bottom 32% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.82, RN 0.81, weekend 3.38. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Green, Dov | Individual | 5% or Greater Indirect Ownership Interest | 43% | 09/01/2023 |
| MD3 Operator Holdco LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 09/01/2023 |
| Mermelstein, Boruch | Individual | 5% or Greater Indirect Ownership Interest | 45% | 09/01/2023 |
| Zager, Nachum | Individual | 5% or Greater Indirect Ownership Interest | 10% | 09/01/2023 |
| Colbert, Ronnie | Individual | W-2 Managing Employee | NOT APPLICABLE | 09/01/2023 |
| Zager, Nachum | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "How often does each resident's doctor visit and review their care in person?"
- "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
- "How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Turtle Creek Rehabilitation and Wellness Center | 1.3 mi | Kensington, MD | ★★☆☆☆ | 1/5 | |
| Complete Care at Wheaton | 1.5 mi | Wheaton, MD | ★★★★★ | 4/5 | |
| Autumn Lake Healthcare at Arcola | 1.7 mi | Silver Spring, MD | ★★★★☆ | 3/5 | |
| Autumn Lake Healthcare at Oakview | 2.0 mi | Silver Spring, MD | ★★★★☆ | 3/5 | |
| Layhill Nursing and Rehabilitation Center | 2.9 mi | Silver Spring, MD | ★☆☆☆☆ | 1/5 | |
| Complete Care at Springbrook | 2.9 mi | Silver Spring, MD | ★★★☆☆ | 3/5 | |
| Woodside Rehab & Nursing | 3.2 mi | Silver Spring, MD | ★★★☆☆ | 3/5 | |
| Harmony Suites Rehabilitation and Wellness Center | 3.5 mi | Silver Spring, MD | ★★☆☆☆ | 1/5 | |
| Tuckerman Rehabilitation and Healthcare Center | 3.6 mi | North Bethesda, MD | ★★★★★ | 5/5 | |
| Autumn Lake Healthcare at Chevy Chase | 3.7 mi | Chevy Chase, MD | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 215048.