Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
SHADY GROVE NURSING AND REHABILITATION CENTER
ROCKVILLE, MD · 154 certified beds · Last Life Safety survey March 13, 2025
CMS Certification Number 215164 · first certified June 1987
Ownership
Operated by LIFEWORKS REHAB · For profit - Limited Liability company
- Ownership changed August 1, 2018 (change of ownership)to SHADY GROVE SNF LLC from 9701 MEDICAL CENTER DRIVE OPERATIONS LLC
Position within MD
24 citations — more than 55% of the 221 certified nursing homes in MD. Compared within MD rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 9 citations; the earlier surveys in the window averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: August 2026 to February 2030. This facility’s last Life Safety survey was March 2025. Facilities in MD are typically surveyed 17–59 months after the last one (median 30), measured over 283 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 24 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
11 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 24 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0908 Keep all essential equipment working safely.
- F-0909 Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
- F-0923 Have enough outside ventilation via a window or mechanical ventilation, or both.
How that compares
Compared with the median facility in MD, and nationally. Surveyors differ markedly between states, so the MD figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 24 |
| Median facility in MD | 22 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 12, 2019 | 9 |
| January 15, 2021 | 6 |
| March 13, 2025 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-03-13 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2021-01-15 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2019-04-12 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2019-04-12 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2019-04-12 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2021-01-15 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2025-03-13 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-03-13 |
What the citations cover
- Smoke Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Egress Deficiencies 3
- Emergency Preparedness Deficiencies 3
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Egress Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
| Services Deficiencies | 1 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 13, 2025 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (March 24, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (March 24, 2025) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (March 24, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 24, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 24, 2025) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (March 24, 2025) |
| K-0525 | Enure that solid fuel-burning fireplaces are not in patient sleeping areas. | Deficient, Provider has date of correction (March 24, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 24, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (March 24, 2025) |
January 15, 2021 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (February 9, 2021) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (February 9, 2021) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (February 9, 2021) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (February 9, 2021) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (February 9, 2021) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (February 9, 2021) |
April 12, 2019 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (July 30, 2019) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (July 30, 2019) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (July 30, 2019) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (July 30, 2019) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (July 30, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 30, 2019) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (July 30, 2019) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (July 30, 2019) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (July 30, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.