12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Rockville, MD
5-star overall rating with 4-star inspections with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
6121 Montrose Road, Rockville, MD
(301) 770-8310
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
558
Certified beds
Average residents
372
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1969-09-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.67
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
1.14
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.98
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.55
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
4.02
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
268
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
74.90
Composite VBP score used to determine payment impact.
Payment multiplier
1.0244
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
10
Baseline 16.65% · Performance 16.32% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
8.71
Baseline 8.23% · Performance 5.25% · Measure score 8.71 · Achievement 8.65 · Improvement 8.71
Total nurse turnover
8.16
Baseline 19.52% · Performance 30.32% · Measure score 8.16 · Achievement 8.16 · Improvement 0
Adjusted total nurse staffing
3.09
Baseline 4.2 hours · Performance 3.96 hours · Measure score 3.09 · Achievement 3.09 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.03% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 1270 · Observed rate 7.95% · Lower 95% interval 8.57% |
| Discharge to community | 66.21% |
50.57%
15.6 pts better
|
Better than the National Rate · Eligible stays 1271 · Observed rate 62.23% · Lower 95% interval 63.04% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.85% |
95.27%
4.6 pts better
|
Numerator 681 · Denominator 682 |
| Falls with major injury | 0.15% |
0.77%
0.6 pts better
|
Numerator 1 · Denominator 682 |
| Discharge self-care score | 54.32% |
53.69%
0.6 pts better
|
Numerator 283 · Denominator 521 |
| Discharge mobility score | 46.83% |
50.94%
4.1 pts worse
|
Numerator 244 · Denominator 521 |
| Pressure ulcers or injuries, new or worsened | 3.52% |
2.29%
1.2 pts worse
|
Numerator 24 · Denominator 682 · Adjusted rate 3.39% |
| Healthcare-associated infections requiring hospitalization | 5.25% |
7.12%
1.9 pts better
|
Better than the National Rate · Eligible stays 788 · Observed rate 4.19% · Lower 95% interval 4.1% |
| Staff COVID-19 vaccination coverage | 8.66% |
8.2%
0.5 pts better
|
Numerator 62 · Denominator 716 |
| Staff flu vaccination coverage | 42.37% |
42%
0.4 pts better
|
Numerator 358 · Denominator 845 |
| Discharge function score | 53.17% |
56.45%
3.3 pts worse
|
Numerator 277 · Denominator 521 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 123 · Denominator 123 |
| Transfer of health information to patient | 99.78% |
96.28%
3.5 pts better
|
Numerator 462 · Denominator 463 |
| Resident COVID-19 vaccinations up to date | 44.3% |
25.2%
19.1 pts better
|
Numerator 140 · Denominator 316 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.3
0.1 pts worse
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
91.9%
1.2 pts better
|
93.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 95.0% · Q3 91.8% · Q4 93.2% · 4Q avg 93.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
96.6%
2.5 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
2.3%
2.5 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.7% · Q3 5.1% · Q4 4.5% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.5% |
21.4%
12.9 pts better
|
11.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 8.0% · Q3 7.6% · Q4 10.2% · 4Q avg 8.5% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
5.7%
3.3 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.2% · Q3 2.5% · Q4 1.7% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.9% |
16.1%
0.8 pts worse
|
19.6%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 16.4% · Q3 17.2% · Q4 18.0% · 4Q avg 16.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.2% |
15.3%
1.9 pts worse
|
16.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 17.7% · Q3 17.1% · Q4 15.9% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.3% |
0.0%
0.3 pts worse
|
0.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.3% · Q2 0.3% · Q3 0.3% · Q4 0.3% · 4Q avg 0.3% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.9% |
26.6%
9.7 pts better
|
16.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 22.5% · Q3 10.5% · Q4 8.0% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.0% |
22.9%
2.9 pts better
|
14.9%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 24.5% · Q3 14.8% · Q4 13.9% · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.7%
0.5 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.9% · Q3 0.7% · Q4 0.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.5%
0.4 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.0% · Q3 3.2% · Q4 2.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.0% |
25.4%
4.4 pts better
|
19.8%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 20.2% · Q3 15.9% · Q4 23.5% · 4Q avg 21.0% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
6.3%
0.1 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 6.4% · Q3 6.2% · Q4 6.9% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.3% |
78.4%
8.9 pts better
|
81.7%
5.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 78.9% · Q2 87.3% · Q3 91.4% · Q4 92.0% · 4Q avg 87.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.9% |
9.9%
4 pts better
|
12.0%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.9% · Observed 5.3% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.3%
0.1 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.6% · Q3 0.6% · Q4 2.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.7% |
80.6%
0.1 pts better
|
79.7%
1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.3% |
21.2%
0.9 pts better
|
23.9%
3.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.3% · Observed 17.3% · Expected 20.3% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-04-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-18
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-18
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-18
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-04-18
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-04-18
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-02-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-21
Fire Safety
Meet other general requirements.
Corrected 2020-02-21
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2020-02-21
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2020-02-21
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2020-02-21
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-02-21
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2020-02-21
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-02-21
Fire Safety
Construct fire resistant interior walls.
Corrected 2020-02-21
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-02-21
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-01-02
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-01-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-01-12
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-12-14
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-28
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-28
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-28
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-03-28
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-28
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-03-28
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-28
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-28
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-03-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-28
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-28
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-28
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-03-28
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-03-28
Health
Provide or obtain dental services for each resident.
Corrected 2025-03-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-01-28
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2020-01-28
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2020-01-28
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-01-24
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2019-01-24
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-01-24
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-01-24
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-01-24
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-01-24
Penalties and ownership
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
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