Maryland ›Rockville

Shady Grove Nursing and Rehabilitation Center

9701 Medical Center Drive, Rockville, MD 20850 · Montgomery County · 154 certified beds · avg 139 residents/day · certified since Jun 5, 1987

Part of chain: LIFEWORKS REHAB (64 facilities, chain avg rating 2.1★)

1/5
Health inspection rating (on-site)
1
Serious findings on record
$8,278
Fines, last 3 years
3.41
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5

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.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Jun 16, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Aug 14, 2025 (Deficient, Provider has date of correction)

All citations in the current public record (88)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Jun 15, 2026E · Potential for harm, repeatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jun 15, 2026D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
May 8, 2026D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Apr 13, 2026D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Dec 19, 2025D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
Dec 19, 2025D · Potential for harm, one-offThe 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. · from a complaint
Jul 17, 2025D · Potential for harm, one-offThe facility did not make sure care was delivered by qualified people following each resident's written care plan — the individualized document that spells out exactly what care that resident is supposed to receive. · from a complaint
Jun 16, 2025▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jun 16, 2025D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint
Jun 16, 2025D · Potential for harm, one-offThe 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
Jun 16, 2025D · Potential for harm, one-offThe 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. · from a complaint
Mar 13, 2025F · Potential for harm, facility-wideThe 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
Mar 13, 2025E · Potential for harm, repeatedThe 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.
Mar 13, 2025E · Potential for harm, repeatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Mar 13, 2025E · Potential for harm, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Mar 13, 2025E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 13, 2025E · Potential for harm, repeatedThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Mar 13, 2025D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Mar 13, 2025D · Potential for harm, one-offThe facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time.
Mar 13, 2025D · Potential for harm, one-offThe 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.
Mar 13, 2025D · Potential for harm, one-offThe facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Mar 13, 2025D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Mar 13, 2025D · Potential for harm, one-offThe facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out.
Mar 13, 2025D · Potential for harm, one-offThe 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.
Mar 13, 2025D · Potential for harm, one-offThe facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly.
Mar 13, 2025D · Potential for harm, one-offThe 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.
Mar 13, 2025D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Mar 13, 2025D · Potential for harm, one-offThe facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Mar 13, 2025D · Potential for harm, one-offThe 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.
Mar 13, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Mar 13, 2025D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Mar 13, 2025D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Mar 13, 2025D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it.
Mar 13, 2025D · Potential for harm, one-offThe facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Mar 13, 2025D · Potential for harm, one-offThe facility admitted a resident without a doctor's order, or did not make sure each resident stayed under a doctor's ongoing care.
Mar 13, 2025D · Potential for harm, one-offThe 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
Mar 13, 2025D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Mar 13, 2025D · Potential for harm, one-offThe 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.
Mar 13, 2025D · Potential for harm, one-offThe 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.
Mar 13, 2025D · Potential for harm, one-offThe facility did not provide routine dental care and 24-hour emergency dental care for residents.
Mar 13, 2025D · Potential for harm, one-offThe 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.
Mar 13, 2025D · Potential for harm, one-offThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Mar 13, 2025D · Potential for harm, one-offThe facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames.
Mar 13, 2025E · Potential for harm, repeatedThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Mar 13, 2025D · Potential for harm, one-offThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint
Mar 13, 2025D · Potential for harm, one-offThe 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
Mar 13, 2025D · Potential for harm, one-offThe facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint
Mar 26, 2024D · Potential for harm, one-offThe facility did not honor residents' right to receive the visitors they choose, at the times they choose. · from a complaint
Mar 26, 2024D · Potential for harm, one-offThe 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
Mar 26, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Mar 26, 2024D · Potential for harm, one-offThe facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. · from a complaint
Mar 26, 2024D · Potential for harm, one-offThe 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
Mar 26, 2024D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Mar 26, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Mar 26, 2024D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint
Mar 26, 2024D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Mar 26, 2024D · Potential for harm, one-offThe facility did not have enough fresh-air ventilation, whether through windows, mechanical systems, or both. · from a complaint
Jan 15, 2021F · Potential for harm, facility-wideThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Jan 15, 2021E · Potential for harm, repeatedThe 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.
Jan 15, 2021E · Potential for harm, repeatedThe facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Jan 15, 2021E · Potential for harm, repeatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jan 15, 2021E · Potential for harm, repeatedThe 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.
Jan 15, 2021E · Potential for harm, repeatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jan 15, 2021E · Potential for harm, repeatedThe 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.
Jan 15, 2021D · Potential for harm, one-offThe 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.
Jan 15, 2021D · Potential for harm, one-offThe 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.
Jan 15, 2021D · Potential for harm, one-offThe 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.
Jan 15, 2021D · Potential for harm, one-offThe 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.
Jan 15, 2021D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jan 15, 2021D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Jan 15, 2021D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Apr 12, 2019F · Potential for harm, facility-wideThe 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.
Apr 12, 2019E · Potential for harm, repeatedThe 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.
Apr 12, 2019D · Potential for harm, one-offThe facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time.
Apr 12, 2019D · Potential for harm, one-offThe 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.
Apr 12, 2019D · Potential for harm, one-offThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Apr 12, 2019D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Apr 12, 2019D · Potential for harm, one-offThe 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.
Apr 12, 2019D · Potential for harm, one-offThe 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.
Apr 12, 2019D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Apr 12, 2019D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Apr 12, 2019D · Potential for harm, one-offThe 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.
Apr 12, 2019D · Potential for harm, one-offThe 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.
Apr 12, 2019D · Potential for harm, one-offThe 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.
Apr 12, 2019D · Potential for harm, one-offThe facility did not bring in qualified outside professionals to provide a required service when it didn't have a qualified professional on staff.
Apr 12, 2019C · Minimal risk, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 12, 2019B · Minimal risk, repeatedThe 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.
Apr 12, 2019B · Minimal risk, repeatedThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (14 → 32).

YearCitationsSerious (G–L)Worst severity that year
2019170F
2021140F
2024100D
2025431G ▲
202640E

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)

1 fine totaling $8,278.

DateTypeAmount / length
Jun 16, 2025Fine$8,278

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityMaryland avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.413.833.95bottom 45% in Maryland; bottom 32% in the U.S.
Registered Nurse hours0.630.830.69bottom 40% in Maryland; top 44% in the U.S.
Weekend total nurse staffing3.113.433.50bottom 45% in Maryland; bottom 37% in the U.S.
Weekend RN hours (not acuity-adjusted)0.440.630.48bottom 37% in Maryland; top 41% in the U.S.
Total nursing staff turnover (%)30.640.245.8top 23% in Maryland; top 15% in the U.S.
RN turnover (%)39.138.742.9bottom 47% in Maryland; top 45% 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 3.60, RN 0.67, weekend 3.29. 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 / managerTypeRoleStakeSince
Birnbaum, IsraelIndividual5% or Greater Indirect Ownership Interest37%05/01/2021
Kohn, AvrohomIndividual5% or Greater Indirect Ownership Interest10%08/01/2018
Rma Equity LLCOrganization5% or Greater Indirect Ownership Interest10%07/13/2023
Thunder Health Holdco LLCOrganization5% or Greater Direct Ownership Interest100%07/01/2018
Birnbaum, IsraelIndividualW-2 Managing EmployeeNOT APPLICABLE08/01/2018

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

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Facility data as of CMS processing date 2026-08-01. CCN 215164.