8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
13 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Gaithersburg, MD
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
301 Russell Avenue, Gaithersburg, MD
(301) 216-4004
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
285
Certified beds
Average residents
162
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Asbury Communities
Operator or chain grouping
Approved since
1975-04-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 4 overall / 4 health / 3 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
RN hours / resident day
1.00
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.84
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
3.96
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.84
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.53
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.82
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.00
CMS adjusted RN staffing hours
Adjusted total hours
3.97
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
19%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
2,625
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.67
Composite VBP score used to determine payment impact.
Payment multiplier
1.0025
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.97
Baseline 18.46% · Performance 20.52% · Measure score 1.97 · Achievement 1.97 · Improvement 0
Healthcare-associated infections
4.34
Baseline 7.33% · Performance 6.54% · Measure score 4.34 · Achievement 4.34 · Improvement 2.90
Total nurse turnover
10
Baseline 19.89% · Performance 17.28% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
3.16
Baseline 4.47 hours · Performance 3.98 hours · Measure score 3.16 · Achievement 3.16 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.08% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 714 · Observed rate 7.7% · Lower 95% interval 8.13% |
| Discharge to community | 61.68% |
50.57%
11.1 pts better
|
Better than the National Rate · Eligible stays 714 · Observed rate 60.92% · Lower 95% interval 59.05% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.76% |
95.27%
4.5 pts better
|
Numerator 424 · Denominator 425 |
| Falls with major injury | 0.71% |
0.77%
0.1 pts better
|
Numerator 3 · Denominator 425 |
| Discharge self-care score | 67.91% |
53.69%
14.2 pts better
|
Numerator 218 · Denominator 321 |
| Discharge mobility score | 66.04% |
50.94%
15.1 pts better
|
Numerator 212 · Denominator 321 |
| Pressure ulcers or injuries, new or worsened | 1.65% |
2.29%
0.6 pts better
|
Numerator 7 · Denominator 425 · Adjusted rate 1.34% |
| Healthcare-associated infections requiring hospitalization | 6.54% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 495 · Observed rate 5.05% · Lower 95% interval 4.33% |
| Staff COVID-19 vaccination coverage | 2.17% |
8.2%
6 pts worse
|
Numerator 9 · Denominator 414 |
| Staff flu vaccination coverage | 97.77% |
42%
55.8 pts better
|
Numerator 307 · Denominator 314 |
| Discharge function score | 67.6% |
56.45%
11.1 pts better
|
Numerator 217 · Denominator 321 |
| Transfer of health information to provider | 96.92% |
95.95%
1 pts better
|
Numerator 63 · Denominator 65 |
| Transfer of health information to patient | 99.33% |
96.28%
3 pts better
|
Numerator 298 · Denominator 300 |
| Resident COVID-19 vaccinations up to date | 37.31% |
25.2%
12.1 pts better
|
Numerator 75 · Denominator 201 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.3
0.2 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.2
0.8 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
91.9%
7.5 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 100.0% · Q3 99.2% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
96.6%
1.9 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
2.3%
0.5 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 2.5% · Q4 4.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
21.4%
18 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.3% · Q3 1.0% · Q4 5.1% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
5.7%
0.9 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.0% · Q3 7.3% · Q4 4.7% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.1% |
16.1%
5 pts better
|
19.6%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 10.7% · Q3 11.5% · Q4 10.3% · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.8% |
15.3%
2.5 pts better
|
16.7%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 11.2% · Q3 13.3% · Q4 13.0% · 4Q avg 12.8% · 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 | 28.5% |
26.6%
1.9 pts worse
|
16.3%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.7% · Q3 28.1% · Q4 23.5% · 4Q avg 28.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.9% |
22.9%
1 pts worse
|
14.9%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 25.5% · Q3 19.2% · Q4 17.6% · 4Q avg 23.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.7%
0.3 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.5%
0.1 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.8% · Q3 1.7% · Q4 2.5% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.4% |
25.4%
4 pts better
|
19.8%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 25.5% · Q3 21.3% · Q4 16.9% · 4Q avg 21.4% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
6.3%
1.3 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 5.9% · Q3 7.9% · Q4 4.6% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
78.4%
18.9 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 96.2% · Q3 97.4% · Q4 97.4% · 4Q avg 97.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
9.9%
2.2 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 6.8% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.3%
0.4 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.0% · Q3 0.9% · Q4 0.5% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.0% |
80.6%
16.4 pts better
|
79.7%
17.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.6% |
21.2%
1.6 pts better
|
23.9%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 17.2% · Expected 20.9% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (3 deficiencies)
13 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Rights (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-28
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-28
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-28
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-05-28
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-05-28
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-28
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-28
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-28
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-28
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-28
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-05-28
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-05-28
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-28
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-04-15
Fire Safety
Construct fire resistant interior walls.
Corrected 2020-04-15
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-04-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-04-15
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2020-04-15
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-04-15
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 2019-03-15
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2019-03-15
Fire Safety
Meet other general requirements.
Corrected 2019-03-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-03-15
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-03-15
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-03-15
Inspection history
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-15
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 2025-05-15
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-15
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 2025-05-15
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-05-15
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 2025-05-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-15
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-05-15
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-03-14
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-14
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-14
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-14
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-14
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 2020-06-11
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2020-06-11
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2020-06-11
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2020-06-11
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-06-11
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2020-06-11
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2020-06-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-06-11
Health
Provide and implement an infection prevention and control program.
Corrected 2020-06-11
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-03-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-03-07
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 2019-03-07
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-07
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-03-07
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-03-07
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 2019-03-07
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
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Rockville, MD
2-star overall rating with 1-star inspections with $12,735 in total fines with 43 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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