Rockville, MD

The Village At Rockville

3-star overall rating with 2-star inspections with $17,345 in total fines with 21 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

9701 Veirs Drive, Rockville, MD

(301) 424-9560

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

160

Certified beds

Average residents

136

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

National Lutheran Communities & Services

Operator or chain grouping

Approved since

1980-07-25

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

2 facilities

Chain averages 4 overall / 3 health / 4 staffing / 5 quality stars

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

Hours and turnover

RN hours / resident day

0.82

Registered nurse staffing · state 0.81 · national 0.68

LPN hours / resident day

1.12

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.13

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

4.07

All reported nurse hours · state 3.87 · national 3.89

Licensed hours

1.94

RN + LPN hours · state 1.72 · national 1.54

Weekend hours

3.69

Weekend nurse staffing · state 3.46 · national 3.43

Weekend RN hours

0.57

Weekend registered nurse coverage · state 0.61 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.78

CMS adjusted RN staffing hours

Adjusted total hours

3.88

CMS adjusted total nurse staffing hours

Case-mix index

1.44

Higher values indicate more complex resident acuity

RN turnover

31%

Annual RN turnover · state 40% · national 45%

Total nurse turnover

39%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

449

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

69.56

Composite VBP score used to determine payment impact.

Payment multiplier

1.0222

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

10

Baseline 13.39% · Performance 14.26% · Measure score 10 · Achievement 10 · Improvement 0

Healthcare-associated infections

9.41

Baseline 3.94% · Performance 5.02% · Measure score 9.41 · Achievement 9.41 · Improvement 0

Total nurse turnover

5.34

Baseline 34.06% · Performance 41.84% · Measure score 5.34 · Achievement 5.34 · Improvement 0

Adjusted total nurse staffing

3.07

Baseline 4.06 hours · Performance 3.95 hours · Measure score 3.07 · Achievement 3.07 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 9.67%
10.72%
1.1 pts better
No Different than the National Rate · Eligible stays 558 · Observed rate 6.99% · Lower 95% interval 8.06%
Discharge to community 62.81%
50.57%
12.2 pts better
Better than the National Rate · Eligible stays 547 · Observed rate 62.34% · Lower 95% interval 58.78%
Medicare spending per beneficiary 0.92
1.02
0.1 pts better
Drug regimen review with follow-up 80.97%
95.27%
14.3 pts worse
Numerator 285 · Denominator 352
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 352
Discharge self-care score 46.05%
53.69%
7.6 pts worse
Numerator 134 · Denominator 291
Discharge mobility score 31.62%
50.94%
19.3 pts worse
Numerator 92 · Denominator 291
Pressure ulcers or injuries, new or worsened 3.69%
2.29%
1.4 pts worse
Numerator 13 · Denominator 352 · Adjusted rate 3.06%
Healthcare-associated infections requiring hospitalization 5.02%
7.12%
2.1 pts better
No Different than the National Rate · Eligible stays 386 · Observed rate 3.11% · Lower 95% interval 3.5%
Staff COVID-19 vaccination coverage 19.12%
8.2%
10.9 pts better
Numerator 65 · Denominator 340
Staff flu vaccination coverage 97.89%
42%
55.9 pts better
Numerator 372 · Denominator 380
Discharge function score 44.67%
56.45%
11.8 pts worse
Numerator 130 · Denominator 291
Transfer of health information to provider 94.03%
95.95%
1.9 pts worse
Numerator 63 · Denominator 67
Transfer of health information to patient 96.93%
96.28%
0.7 pts better
Numerator 221 · Denominator 228
Resident COVID-19 vaccinations up to date 34.48%
25.2%
9.3 pts better
Numerator 60 · Denominator 174

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.2
1.3
0.1 pts better
1.9
0.7 pts better
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 0.6
1.2
0.6 pts better
1.8
1.2 pts better
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 84.8%
91.9%
7.1 pts worse
93.4%
8.6 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 64.8% · Q2 85.7% · Q3 96.0% · Q4 93.3% · 4Q avg 84.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 96.5%
96.6%
0.1 pts worse
95.5%
1 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.5%
Percentage of long-stay residents experiencing one or more falls with major injury 1.9%
2.3%
0.4 pts better
3.3%
1.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 3.0% · Q4 2.9% · 4Q avg 1.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 3.3%
21.4%
18.1 pts better
11.4%
8.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 4.0% · Q3 2.2% · Q4 1.0% · 4Q avg 3.3%
Percentage of long-stay residents who lose too much weight 5.0%
5.7%
0.7 pts better
5.4%
0.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.3% · Q3 7.1% · Q4 6.5% · 4Q avg 5.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 12.1%
16.1%
4 pts better
19.6%
7.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 9.7% · Q3 13.8% · Q4 16.3% · 4Q avg 12.1%
Percentage of long-stay residents who received an antipsychotic medication 23.1%
15.3%
7.8 pts worse
16.7%
6.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 27.6% · Q3 22.4% · Q4 18.7% · 4Q avg 23.1% · 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 40.5%
26.6%
13.9 pts worse
16.3%
24.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 34.9% · Q2 52.2% · Q3 30.5% · Q4 44.1% · 4Q avg 40.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 25.3%
22.9%
2.4 pts worse
14.9%
10.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 29.9% · Q2 28.6% · Q3 25.7% · Q4 16.4% · 4Q avg 25.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.2%
0.7%
0.5 pts better
1.0%
0.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 1.2%
1.5%
0.3 pts better
1.7%
0.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 22.1%
25.4%
3.3 pts better
19.8%
2.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 20.6% · Q3 23.3% · Q4 21.4% · 4Q avg 22.1%
Percentage of long-stay residents with pressure ulcers 6.1%
6.3%
0.2 pts better
5.1%
1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 6.6% · Q3 4.6% · Q4 5.3% · 4Q avg 6.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 90.0%
78.4%
11.6 pts better
81.7%
8.3 pts better
Short Stay · 2024Q4-2025Q3 · Q1 86.5% · Q2 86.6% · Q3 92.2% · Q4 95.3% · 4Q avg 90.0%
Percentage of short-stay residents who had an outpatient emergency department visit 5.6%
9.9%
4.3 pts better
12.0%
6.4 pts better
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 4.9% · 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 1.3% · Q2 1.3% · Q3 1.4% · Q4 0.8% · 4Q avg 1.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 91.6%
80.6%
11 pts better
79.7%
11.9 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 14.8%
21.2%
6.4 pts better
23.9%
9.1 pts better
Short Stay · 20240701-20250630 · Adjusted 14.8% · Observed 12.7% · Expected 20.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-11 · Fire 2024-10-11

21 health deficiencies

Top issue: Resident Rights (7 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2019-10-24 · Fire 2019-10-24

7 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2018-07-19 · Fire 2018-07-19

10 health deficiencies

Top issue: Resident Rights (4 deficiencies)

3 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-10-11

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2024-12-04

F · Potential for more than minimal harm 2024-10-11

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-12-04

F · Potential for more than minimal harm 2024-10-11

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-12-04

F · Potential for more than minimal harm 2024-10-11

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-12-17

E · Potential for more than minimal harm 2024-10-11

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-12-04

E · Potential for more than minimal harm 2019-10-24

K321 · Smoke Deficiencies

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 2019-07-10

D · Potential for more than minimal harm 2019-10-24

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2019-07-10

C · Minimal harm 2019-10-24

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2019-07-10

C · Minimal harm 2019-10-24

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2019-07-10

B · Minimal harm 2019-10-24

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-07-10

B · Minimal harm 2019-10-24

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2019-07-10

D · Potential for more than minimal harm 2018-07-19

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2018-07-23

C · Minimal harm 2018-07-19

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2018-07-24

B · Minimal harm 2018-07-19

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2018-07-23

Inspection history

Recent health citations

J · Immediate jeopardy 2024-10-11

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2024-03-27

F · Potential for more than minimal harm 2024-10-11

F941 · Administration Deficiencies

Health

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Corrected 2024-11-22

E · Potential for more than minimal harm 2024-10-11

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2024-11-22

E · Potential for more than minimal harm 2024-10-11

F700 · Quality of Life and Care Deficiencies

Health

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Corrected 2024-11-22

E · Potential for more than minimal harm 2024-10-11

F756 · Pharmacy Service Deficiencies

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 2024-11-22

D · Potential for more than minimal harm 2024-10-11

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-10-11

F580 · Resident Rights Deficiencies

Health

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

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-10-11

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-10-11

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-10-11

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-10-11

F622 · Resident Rights Deficiencies

Health

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-10-11

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-10-11

F624 · Resident Rights Deficiencies

Health

Prepare residents for a safe transfer or discharge from the nursing home.

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-10-11

F625 · Resident Rights Deficiencies

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 2024-11-22

D · Potential for more than minimal harm 2024-10-11

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-10-11

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-10-11

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-10-11

F758 · Pharmacy Service Deficiencies

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 2024-11-22

D · Potential for more than minimal harm 2024-10-11

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-10-11

F842 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-10-11

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-11-22

D · Potential for more than minimal harm 2024-10-11

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-11-22

K · Immediate jeopardy 2019-10-24

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2019-12-09

E · Potential for more than minimal harm 2019-10-24

F657 · Resident Assessment and Care Planning Deficiencies

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 2019-12-09

D · Potential for more than minimal harm 2019-10-24

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2019-12-09

D · Potential for more than minimal harm 2019-10-24

F755 · Pharmacy Service Deficiencies

Health

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

Corrected 2019-12-09

D · Potential for more than minimal harm 2019-10-24

F761 · Pharmacy Service Deficiencies

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 2019-12-09

B · Minimal harm 2019-10-24

F655 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2019-12-09

E · Potential for more than minimal harm 2018-07-19

F625 · Resident Rights Deficiencies

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 2018-08-06

D · Potential for more than minimal harm 2018-07-19

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2018-08-06

D · Potential for more than minimal harm 2018-07-19

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2018-08-06

D · Potential for more than minimal harm 2018-07-19

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2018-08-06

D · Potential for more than minimal harm 2018-07-19

F758 · Pharmacy Service Deficiencies

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 2018-08-06

D · Potential for more than minimal harm 2018-07-19

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2018-08-06

D · Potential for more than minimal harm 2018-07-19

F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Corrected 2018-08-06

C · Minimal harm 2018-07-19

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2018-08-06

B · Minimal harm 2018-07-19

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2018-08-06

B · Minimal harm 2018-07-19

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2018-08-06

Penalties and ownership

What sits behind the stars

$17,345 2024-10-11

Fine

Fine · fine $17,345

Fine

Ownership

Bradshaw, Lawrence

Corporate Officer · Individual

0% 3 facilities 2009-10-01
Casner, Donna

Corporate Officer · Individual

0% 2 facilities 2018-06-25
Casner, Donna

W-2 Managing Employee · Individual

0% 2 facilities 2018-06-25
Hreben, Kyle

Corporate Director · Individual

0% 2 facilities 2018-04-30
Mazza, Richard

Corporate Officer · Individual

0% 2 facilities 2018-02-12
Walters, Cynthia

Corporate Officer · Individual

0% 5 facilities 2016-10-03

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