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COMPLETE CARE AT SPRINGBROOK

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COMPLETE CARE AT SPRINGBROOK is a for profit - limited liability company facility in SILVER SPRING, MD with 93 certified beds and a 4-star overall CMS rating. The facility has 39 deficiency records on file.

12325 NEW HAMPSHIRE AVENUE, SILVER SPRING, MD 20904

Phone: 3016224600

Overall Rating

4/5

Health Inspection

3/5

Staffing

2/5

Quality Measures

5/5

Long-Stay Quality

5/5

Facility Information

Provider Number
215052
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
Beds
93
Residents
87
In Hospital
No
County
Montgomery
Last Inspection
Sep 16, 2020

Staffing Data

RN Hours
0.60 (nat'l avg: 0.68)
LPN Hours
0.93
CNA Hours
1.80
Total Nursing Hours
3.33 (nat'l avg: 3.89)
PT Hours
0.07
Nursing Turnover
39.2%
RN Turnover
50.0%

What the CMS Record Reveals About COMPLETE CARE AT SPRINGBROOK

COMPLETE CARE AT SPRINGBROOK operates 93 certified beds in SILVER SPRING, MD with approximately 87 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (2★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.

The inspection file contains 39 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 3.33 total nursing hours per resident day (national average 3.89), with RN coverage at 0.60 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.

Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, COMPLETE CARE AT SPRINGBROOK falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 39.2%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.

Deficiency History (39 most recent)

E — Pattern - Minimal harm Dec 19, 2025 Tag: 0921

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Category: Environmental Deficiencies

Corrected: Jan 19, 2026

E — Pattern - Minimal harm Dec 19, 2025 Tag: 0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Category: Environmental Deficiencies

Corrected: Jan 19, 2026

D — Isolated - Minimal harm Dec 19, 2025 Tag: 0761

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Category: Pharmacy Service Deficiencies

Corrected: Jan 19, 2026

D — Isolated - Minimal harm Dec 19, 2025 Tag: 0759

Ensure medication error rates are not 5 percent or greater.

Category: Pharmacy Service Deficiencies

Corrected: Jan 19, 2026

D — Isolated - Minimal harm Dec 19, 2025 Tag: 0755

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Category: Pharmacy Service Deficiencies

Corrected: Jan 19, 2026

E — Pattern - Minimal harm Dec 19, 2025 Tag: 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jan 19, 2026

D — Isolated - Minimal harm Mar 14, 2025 Tag: 0800

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Category: Nutrition and Dietary Deficiencies

Corrected: Apr 30, 2025

E — Pattern - Minimal harm Mar 14, 2025 Tag: 0755

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Category: Pharmacy Service Deficiencies

Corrected: Apr 30, 2025

D — Isolated - Minimal harm Mar 14, 2025 Tag: 0656

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Apr 30, 2025

D — Isolated - Minimal harm Dec 18, 2024 Tag: 0842

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jan 27, 2025

D — Isolated - Minimal harm Dec 18, 2024 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Jan 27, 2025

D — Isolated - Minimal harm Dec 18, 2024 Tag: 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Category: Quality of Life and Care Deficiencies

Corrected: Jan 27, 2025

D — Isolated - Minimal harm Dec 18, 2024 Tag: 0610

Respond appropriately to all alleged violations.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Jan 27, 2025

D — Isolated - Minimal harm Dec 18, 2024 Tag: 0609

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Jan 27, 2025

E — Pattern - Minimal harm Sep 16, 2020 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Oct 16, 2020

E — Pattern - Minimal harm Sep 16, 2020 Tag: 0761

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Category: Pharmacy Service Deficiencies

Corrected: Oct 16, 2020

D — Isolated - Minimal harm Sep 16, 2020 Tag: 0688

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Category: Quality of Life and Care Deficiencies

Corrected: Oct 16, 2020

D — Isolated - Minimal harm Sep 16, 2020 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Oct 16, 2020

D — Isolated - Minimal harm Sep 16, 2020 Tag: 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Oct 16, 2020

D — Isolated - Minimal harm Sep 16, 2020 Tag: 0585

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Category: Resident Rights Deficiencies

Corrected: Oct 16, 2020

D — Isolated - Minimal harm Sep 16, 2020 Tag: 0583

Keep residents' personal and medical records private and confidential.

Category: Resident Rights Deficiencies

Corrected: Oct 16, 2020

B — Pattern - No harm Sep 12, 2019 Tag: 0842

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Oct 28, 2019

E — Pattern - Minimal harm Sep 12, 2019 Tag: 0695

Provide safe and appropriate respiratory care for a resident when needed.

Category: Quality of Life and Care Deficiencies

Corrected: Oct 28, 2019

D — Isolated - Minimal harm Sep 12, 2019 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Oct 28, 2019

D — Isolated - Minimal harm Sep 12, 2019 Tag: 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Oct 28, 2019

D — Isolated - Minimal harm Sep 12, 2019 Tag: 0657

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Oct 28, 2019

D — Isolated - Minimal harm Sep 12, 2019 Tag: 0656

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Oct 28, 2019

D — Isolated - Minimal harm Sep 12, 2019 Tag: 0655

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Oct 28, 2019

B — Pattern - No harm Sep 12, 2019 Tag: 0582

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Category: Resident Rights Deficiencies

Corrected: Oct 28, 2019

E — Pattern - Minimal harm Mar 29, 2019 Tag: 0840

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Category: Administration Deficiencies

Corrected: May 17, 2019

D — Isolated - Minimal harm Mar 29, 2019 Tag: 0761

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Category: Pharmacy Service Deficiencies

Corrected: May 17, 2019

D — Isolated - Minimal harm Mar 29, 2019 Tag: 0755

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Category: Pharmacy Service Deficiencies

Corrected: May 17, 2019

D — Isolated - Minimal harm Mar 29, 2019 Tag: 0740

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Category: Quality of Life and Care Deficiencies

Corrected: May 17, 2019

J — Isolated - Jeopardy Mar 29, 2019 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Jan 24, 2019

D — Isolated - Minimal harm Mar 29, 2019 Tag: 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Category: Quality of Life and Care Deficiencies

Corrected: May 17, 2019

D — Isolated - Minimal harm Mar 29, 2019 Tag: 0657

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: May 17, 2019

D — Isolated - Minimal harm Mar 29, 2019 Tag: 0580

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Category: Resident Rights Deficiencies

Corrected: May 17, 2019

D — Isolated - Minimal harm Mar 29, 2019 Tag: 0572

Give residents a notice of rights, rules, services and charges.

Category: Resident Rights Deficiencies

Corrected: May 17, 2019

D — Isolated - Minimal harm Mar 29, 2019 Tag: 0551

Give the resident's representative the ability to exercise the resident's rights.

Category: Resident Rights Deficiencies

Corrected: May 17, 2019

Quality Measures

Measure Type Score Used in Rating
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay 20.5% Yes
Percentage of long-stay residents who lose too much weight Long Stay 2.7% No
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay 0.0% Yes
Percentage of long-stay residents with a urinary tract infection Long Stay 0.4% Yes
Percentage of long-stay residents who have depressive symptoms Long Stay 71.7% No
Percentage of long-stay residents who were physically restrained Long Stay 0.0% No
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay 1.1% Yes
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay 100.0% No
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay 98.7% No
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay 1.1% Yes
Percentage of long-stay residents whose ability to walk independently worsened Long Stay 11.8% Yes
Percentage of long-stay residents who received an antianxiety or hypnotic medication Long Stay 6.5% No
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Long Stay 100.0% No
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Short Stay 100.0% No
Percentage of long-stay residents with pressure ulcers Long Stay 3.8% Yes
Percentage of long-stay residents with new or worsened bowel or bladder incontinence Long Stay 24.7% No
Percentage of long-stay residents who received an antipsychotic medication Long Stay 6.1% Yes

Penalty History

No penalties on record.

Frequently Asked Questions

What is the overall CMS rating for COMPLETE CARE AT SPRINGBROOK?
COMPLETE CARE AT SPRINGBROOK has an overall CMS rating of 4 out of 5 stars. This rating combines health inspection results (3★), staffing levels (2★), and quality measures (5★).
What are the staffing levels at COMPLETE CARE AT SPRINGBROOK?
COMPLETE CARE AT SPRINGBROOK reports 3.33 total nursing hours per resident day (national average: 3.89). RN hours are 0.60 per resident day (national average: 0.68). Nursing staff turnover is 39.2%.
How many beds does COMPLETE CARE AT SPRINGBROOK have?
COMPLETE CARE AT SPRINGBROOK has 93 certified beds with approximately 87 residents. The facility is located at 12325 NEW HAMPSHIRE AVENUE, SILVER SPRING, MD 20904.
Does COMPLETE CARE AT SPRINGBROOK have any deficiencies on record?
Yes, COMPLETE CARE AT SPRINGBROOK has 39 deficiencies on record from recent inspections. Of these, 1 are classified as causing actual harm or jeopardy.
Has COMPLETE CARE AT SPRINGBROOK received any fines or penalties?
No, COMPLETE CARE AT SPRINGBROOK has no fines or penalties on record.
Who owns COMPLETE CARE AT SPRINGBROOK?
COMPLETE CARE AT SPRINGBROOK is classified as "For profit - Limited Liability company" ownership. The facility type is "Medicare and Medicaid".
When was COMPLETE CARE AT SPRINGBROOK last inspected?
The most recent health inspection for COMPLETE CARE AT SPRINGBROOK was on Sep 16, 2020. The facility received a health inspection rating of 3 out of 5 stars.
What quality measures are tracked for COMPLETE CARE AT SPRINGBROOK?
COMPLETE CARE AT SPRINGBROOK is evaluated on 17 quality measures, of which 8 are used in the CMS star rating calculation. These include measures for both long-stay and short-stay residents covering areas like infections, falls, pressure ulcers, and medication use.

Data Sources

Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.

Related

Data sourced from official U.S. government datasets. See our methodology for details. Retrieved and formatted by PlainNursing Editorial