4 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Gaithersburg, MD
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
19301 Watkins Mill Road, Gaithersburg, MD
(301) 527-2500
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
147
Certified beds
Average residents
161
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-03-14
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
0.88
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.17
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
2.80
CMS adjusted total nurse staffing hours
Case-mix index
1.71
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
8,483
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9842
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0.52
Baseline 19.96% · Performance 21.19% · Measure score 0.52 · Achievement 0.52 · Improvement 0
Healthcare-associated infections
1.18
Baseline 8.03% · Performance 7.52% · Measure score 1.18 · Achievement 1.05 · Improvement 1.18
Total nurse turnover
8.95
Baseline 29.67% · Performance 27.12% · Measure score 8.95 · Achievement 8.95 · Improvement 4.79
Adjusted total nurse staffing
0
Baseline 3.33 hours · Performance 3.05 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 16.55% |
10.72%
5.8 pts worse
|
Worse than the National Rate · Eligible stays 599 · Observed rate 17.53% · Lower 95% interval 14.18% |
| Discharge to community | 60.02% |
50.57%
9.5 pts better
|
Better than the National Rate · Eligible stays 625 · Observed rate 53.6% · Lower 95% interval 55.65% |
| Medicare spending per beneficiary | 1.36 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 377 · Denominator 377 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 377 |
| Discharge self-care score | 68.33% |
53.69%
14.6 pts better
|
Numerator 151 · Denominator 221 |
| Discharge mobility score | 74.21% |
50.94%
23.3 pts better
|
Numerator 164 · Denominator 221 |
| Pressure ulcers or injuries, new or worsened | 2.39% |
2.29%
0.1 pts worse
|
Numerator 9 · Denominator 377 · Adjusted rate 1.47% |
| Healthcare-associated infections requiring hospitalization | 7.52% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 318 · Observed rate 7.23% · Lower 95% interval 4.96% |
| Staff COVID-19 vaccination coverage | 5.08% |
8.2%
3.1 pts worse
|
Numerator 10 · Denominator 197 |
| Staff flu vaccination coverage | 95.51% |
42%
53.5 pts better
|
Numerator 170 · Denominator 178 |
| Discharge function score | 84.16% |
56.45%
27.7 pts better
|
Numerator 186 · Denominator 221 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 95 · Denominator 95 |
| Transfer of health information to patient | 99.56% |
96.28%
3.3 pts better
|
Numerator 227 · Denominator 228 |
| Resident COVID-19 vaccinations up to date | 7.32% |
25.2%
17.9 pts worse
|
Numerator 15 · Denominator 205 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.2 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.1 |
1.2
1.1 pts better
|
1.8
1.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.1 · Observed 0.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
91.9%
7.9 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.1% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.6%
3.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
2.3%
0.2 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.0% · Q3 1.9% · Q4 1.8% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 88.9% |
21.4%
67.5 pts worse
|
11.4%
77.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.4% · Q2 84.2% · Q3 90.6% · Q4 100.0% · 4Q avg 88.9% |
| Percentage of long-stay residents who lose too much weight | 7.5% |
5.7%
1.8 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 14.7% · Q3 7.3% · Q4 3.8% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.4% |
16.1%
4.7 pts better
|
19.6%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 11.5% · Q3 11.9% · Q4 13.4% · 4Q avg 11.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.1% |
15.3%
2.2 pts better
|
16.7%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 14.7% · Q3 9.6% · Q4 16.8% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.0% |
26.6%
15.6 pts better
|
16.3%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 14.1% · Q3 14.6% · Q4 11.0% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.3% |
22.9%
6.6 pts better
|
14.9%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 21.7% · Q3 23.9% · Q4 14.1% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.5%
1.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.5% |
25.4%
2.1 pts worse
|
19.8%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 30.9% · Q3 26.1% · Q4 31.4% · 4Q avg 27.5% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
6.3%
1 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 6.2% · Q3 5.9% · Q4 4.3% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
78.4%
18 pts better
|
81.7%
14.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 96.0% · Q3 98.1% · Q4 96.3% · 4Q avg 96.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.8% |
9.9%
3.1 pts better
|
12.0%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.8% · Observed 6.4% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.3%
0.3 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 0.6% · Q4 1.1% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.9% |
80.6%
7.3 pts better
|
79.7%
8.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.8% |
21.2%
0.6 pts worse
|
23.9%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 21.6% · Expected 23.6% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
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 2021-01-28
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2021-01-28
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2021-01-28
Fire Safety
Meet other general requirements.
Corrected 2019-07-30
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 2019-07-30
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2019-07-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-07-30
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-08-03
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-08-03
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 2018-05-25
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2018-05-25
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2018-05-25
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-05-25
Inspection history
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-05-14
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2025-05-14
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 2021-02-17
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-02-17
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-06-12
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 2019-06-12
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-06-12
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2019-06-12
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-06-12
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 2019-06-12
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-06-12
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-06-12
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2019-06-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-06-12
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-06-12
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 2019-06-12
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-06-12
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2019-06-12
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2019-06-12
Health
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.
Corrected 2019-06-12
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2018-06-08
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2018-06-08
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 2018-06-08
Health
Provide and implement an infection prevention and control program.
Corrected 2018-06-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-06-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-06-08
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2018-06-08
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2018-06-08
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2018-06-08
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2018-06-08
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2018-06-08
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2018-06-08
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 2018-06-08
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2018-06-08
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2018-06-08
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2018-06-08
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2018-06-08
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-06-08
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2018-06-08
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
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