Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Montgomery Village Care Center during CMS and state inspections, most recent first.
Failure to establish and document legally authorized resident representatives for two residents with declining cognition. One resident had BIMS scores that fell from normal to severe impairment, with psych notes describing severe confusion, thought blocking, and illogical responses; the other resident’s BIMS scores dropped from normal to near-total impairment. The record for both residents lacked evidence that the facility attempted to identify a surrogate decision maker, and DSS staff could not explain the missing documentation.
Psychotropic medication consent was not properly obtained or documented for several residents. One resident lacked documented evidence that a family member had agreed to serve as surrogate decision maker, another consent form did not identify who signed for the resident, a third resident’s consent form listed the wrong antipsychotic, and a fourth resident had documented confusion and illogical responses despite having consent on file for psychotropic medication.
Failure to establish legal surrogates when residents lacked decision-making capacity: Two residents declined to complete ADs at admission, but later physician certifications showed they lacked capacity due to dementia, and the record did not document any facility attempts to establish a legal surrogate decision maker.
A bathroom shared by two residents had a paper towel dispenser with the front cover missing, leaving brown paper towels exposed. The issue was observed on two survey observations, and the DON was notified. The NHA stated staff use Tels to report broken items, and the Director of Housekeeping said the dispenser still worked by pushing the blue button even though the automatic sensor no longer functioned.
Inaccurate MDS Coding for Resident Receiving Hemodialysis: A resident receiving hemodialysis had an inaccurate MDS because dialysis was not coded in Section O. Staff said they did not code it because they did not see progress note documentation, even though a dialysis communication sheet and dialysis-related physician orders on the MAR and TAR were available in the resident’s record during the look-back period. The VPCS later acknowledged the MDS was not coded accurately and that the resident received hemodialysis.
Missed Care Plan Invitations and Late Quarterly Meetings: Facility staff failed to send care plan meeting invitations to the residents’ responsible parties and did not hold quarterly care plan meetings within the required timeframe for two residents. Records showed invitations were sent to the residents instead of the legal guardian or surrogate decision maker, and the care plan meetings were spaced beyond the quarterly interval required by policy.
A resident receiving IV antibiotic infusions had IV tubing that was not dated or labeled during two observations. On the second observation, the tubing end was not capped and was connected to the lower port. RN stated IV tubing should be changed daily and capped when not in use, but the record contained no physician order or documented direction for tubing changes.
The facility failed to ensure that two residents' EHRs accurately reflected their cognitive status during review of advanced directives. One resident with dementia, a BIMS score of 1, and a physician certification of incapacity was documented as his/her own responsible party, while a discharge summary stated the resident was alert, oriented, and able to understand discharge instructions and sign paperwork. A second resident with dementia, a BIMS score of 1, and a physician certification of incapacity was also listed as his/her own responsible party; the SS director stated residents with incapacity certifications cannot make decisions independently, and the DON acknowledged the concern.
Infection control was deficient when a resident’s oxygen tubing and another resident’s foley catheter were observed on the floor, and the laundry room lacked a door or physical barrier between clean and soiled areas. An RN and an LPN both acknowledged the issues when shown the observations, and the Administrator stated the laundry setup had no separating door and was still being addressed.
A resident with multiple fractures and significant care needs was discharged without a comprehensive care plan, proper coordination with outside providers, or complete discharge instructions. The facility did not ensure necessary medical equipment was ordered or that referrals and follow-up care were arranged, resulting in an incomplete and inadequate discharge process.
A resident discharged after short-term rehab for a fracture received incomplete discharge paperwork, missing key pages and lacking home health agency contact information. The resident's representative was unable to reach social services for clarification and only received the full discharge summary two weeks later. There was also a discrepancy in the discharge date communicated to the home health agency.
Failure to Establish and Document Resident Representatives
Penalty
Summary
The facility failed to properly identify, verify, and document a legally authorized resident representative for residents who lacked capacity. For Resident #8, the record showed a decline in BIMS scores from 14 at admission to 11, then 7, and later 3, along with psychiatry progress notes describing the resident as severely confused, thought blocking, and giving illogical responses. Despite these findings, the record did not show evidence that the facility attempted to establish a surrogate decision maker after the cognitive decline became clear. For Resident #71, the record showed the resident was listed as their own responsible party on readmission, then had a BIMS score of 14 followed by scores of 2 and 1 on later assessments. The record did not show documented evidence that the facility attempted to establish a surrogate decision maker for this resident. During interviews, the Director of Social Services and the Regional Director of Social Work stated that residents with two or more consecutive low BIMS scores would warrant a psychological evaluation and then physician certification for lack of mental capacity, but they could not explain why attempts had not been made for Resident #8, and the Director of Social Services could not provide the requested surrogate decision maker information for either resident.
Psychotropic Medication Consent Not Properly Documented
Penalty
Summary
The facility failed to ensure consent for psychotropic medications was obtained and maintained in accordance with residents’ decision-making capacity for 4 of 5 residents reviewed. For one resident with dementia and delirium, two physicians had certified a lack of decision-making capacity, and the facility identified a family member as the substitute decision maker; however, the record did not show documented evidence that the family member had accepted or agreed to serve in that role, even though the family member later consented to psychotropic medications. For another resident, the psychotropic medication consent form did not document the name or signature of the individual who provided consent, and the ADON acknowledged there was no progress note or other documentation supporting that consent was obtained from the surrogate. For a third resident, the consent form documented approval for Olanzapine, but the medical record showed the resident was prescribed Clozapine for schizophrenia, and the record did not show documented evidence of consent for Clozapine. For a fourth resident, the record showed consent for psychotropic medication, but psychiatry progress notes described the resident as thought blocking, severely confused, and giving illogical responses. During interview, the Divisional Director of Quality Assurance acknowledged the concerns related to the consent forms and the resident’s documented mental status and ability to provide informed consent.
Failure to Establish Legal Surrogates When Residents Lacked Decision-Making Capacity
Penalty
Summary
Facility staff failed to properly manage care choices for residents when no advance directive was in place. Resident #16 was admitted with multiple medical diagnoses including dementia and, at admission, was screened for an advance directive. The record showed the advance directive form was reviewed and a copy was provided, but the resident declined to formulate one. Later, two physicians certified that the resident lacked the capacity to make healthcare decisions due to dementia, and the record did not show documented attempts by the facility to establish a legal surrogate decision maker. Resident #4 was initially admitted in September 2022 and later readmitted in June 2025. At admission, the resident was screened for an advance directive, and the record showed the advance directive form was reviewed and a copy was provided, but the resident declined to formulate one. The record further showed that two physicians certified the resident lacked decision-making capacity due to dementia and delirium, yet there was no documented evidence that the facility attempted to establish a legal surrogate decision maker.
Missing Paper Towel Dispenser Cover in Resident Bathroom
Penalty
Summary
The facility failed to ensure that the environment of the residents’ care area was kept safe and sanitary. During observation of the bathroom shared by Resident #9 and Resident #14, the front cover of the paper towel dispenser was missing, exposing brown paper towels. The dispenser was located next to the mirror on the wall between the toilet and the sink, and the missing cover was observed during the initial survey observation. The missing front cover remained in place when the bathroom was re-observed the next day, with the brown paper towels still exposed. The DON was informed that the dispenser cover was missing and acknowledged the concern. The NHA stated that staff should enter broken items into Tels for Maintenance, and the Director of Housekeeping stated that the dispenser still worked by pushing the blue button even though the cover was defective and the automatic sensor no longer worked.
Inaccurate MDS Coding for Resident Receiving Hemodialysis
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was accurately completed for a resident receiving hemodialysis. During review of Resident #15’s 5-day MDS assessment, Staff #24 stated that hemodialysis was not coded in Section O because there was no documentation in the progress notes showing the resident had attended dialysis, and that there was no other way to determine the information. On further review, the surveyor found a dialysis communication sheet in the dialysis communication book covering the MDS look-back period, and the President of Clinical Services stated that the facility did not consider the dialysis communication book part of the medical record, although dialysis documentation should be part of the medical record. Additional review of the resident’s medical record showed physician orders on the MAR and TAR related to dialysis, indicating documentation was available in the medical record that Resident #15 received dialysis during the MDS look-back period. The President of Clinical Services later acknowledged that the MDS was not coded accurately and that the documentation showed the resident received hemodialysis.
Missed Care Plan Invitations and Late Quarterly Meetings
Penalty
Summary
Facility staff failed to ensure that care plan meeting invitations were sent to the residents’ responsible parties and failed to conduct quarterly care plan meetings within the required timeframe for two residents. One resident’s family member was identified as the legal guardian, but the records showed that care plan meeting invitations were sent to the resident instead of the guardian. The records also showed a care plan meeting in October 2024, with the next meeting not scheduled until March 2026, which exceeded the quarterly timeframe. For another resident, the spouse was identified as the surrogate decision maker, but the care plan meeting invitation was provided to the resident rather than the surrogate. The records showed a care plan meeting in April 2025, with the next meeting not conducted until February 2026, also beyond the required quarterly interval. The Director of Social Services stated that care plan meetings were conducted on admission, quarterly, with changes in condition, or upon request, and that invitations were generally sent one to two weeks before the meeting, but documentation for the required invitations and conference notes for the prior 12 months could not be provided.
Improper IV Tubing Management
Penalty
Summary
The facility failed to follow professional standards of practice when administering intermittent IV antibiotic infusions for Resident #53. On 6/1/2026 and again on 6/3/2026, the surveyor observed the resident’s IV tubing and found that it was not dated or labeled. During the second observation, the end of the IV tubing was not capped and was connected to the lower port. RN #6 stated that IV tubing should be changed every day and that the end of the tubing should be capped when not in use. Record review showed an order for an IV antibiotic every 12 hours, but there was no physician’s order or documented direction for IV tubing changes.
Inaccurate Cognitive Status in EHR
Penalty
Summary
The facility failed to ensure that residents' Electronic Health Records accurately reflected their cognitive status for 2 residents reviewed for advanced directives. Resident #11's EHR identified the resident as his/her responsible party despite a diagnosis of dementia, a BIMS score of 1, and a physician's certification of incapacity to make an informed decision; however, the discharge summary note dated 05/19/26 stated the resident was alert, oriented, verbalized understanding of all discharge instructions, and would sign all necessary discharge paperwork prior to discharge. Resident #93's EHR also identified the resident as his/her responsible party despite a diagnosis of dementia, a BIMS score of 1, and a physician's certification of incapacity to make an informed decision. During interview, the Social Services Director stated that residents with incapacity certifications do not have the ability to make decisions independently, and the DON acknowledged the concern.
Infection Control Lapses in Resident Equipment and Laundry Separation
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility did not maintain the environment in a manner that minimized the potential spread of infection. On 06/01/2026 at 8:57 AM, Resident #1’s oxygen tubing was observed wrapped around the oxygen concentrator, and the nasal cannula portion of the tubing was on the floor. At 8:59 AM, an RN was shown the tubing on the floor and stated that it was an issue; the RN then put on gloves, discarded the tubing, and went to get new oxygen tubing for the resident. The deficiency also involved Resident #17’s foley catheter and the laundry area. On 06/01/2026 at 8:14 AM and again at 9:10 AM, Resident #17’s foley catheter was observed on the floor. At 9:20 AM, an LPN stated the catheter should not be on the floor, put on gloves, and adjusted the foley bag so it was no longer touching the floor. On 06/04/2026 at 11:43 AM, the surveyor observed that there was no door or physical barrier between the clean and soiled areas in the laundry room, and the Administrator stated the laundry room had never had a door separating the sections and that they would look into it. During follow-up on 06/05/2026, the Administrator stated they were still working on the door and acknowledged the lack of a door was a potential infection control concern.
Failure to Implement Effective Discharge Planning and Coordination
Penalty
Summary
The facility failed to implement an effective discharge process for Resident #394, as evidenced by several deficiencies in planning and coordination. The resident, who was admitted following multiple fractures and required maximal to moderate assistance with activities of daily living, was discharged home after insurance coverage ended. Despite the resident's complex needs, including non-weight-bearing status, limited mobility, incontinence, and the need for intermittent self-catheterization, the facility did not develop a comprehensive discharge care plan, coordinate referrals to outside providers, or order the recommended medical equipment. Additionally, the discharge packet was incomplete, lacking a home medication list and other essential information at the time of discharge. The record review and staff interview confirmed that only an initial care conference was held, with no further documented planning or coordination for the resident's transition to home. The discharge paperwork was initiated late and was incomplete, and there was no evidence of proper coordination with home health agencies or vendors for necessary services and equipment. The physician's discharge summary outlined ongoing care needs and follow-up appointments, but the facility did not ensure these were addressed in the discharge process.
Incomplete Discharge Summary and Communication Failure at Discharge
Penalty
Summary
Facility staff failed to provide a completed discharge summary to a resident at the time of discharge. The resident, who had been admitted for short-term rehabilitation following a hospital stay for a fall with fracture, requested to leave the facility and was discharged. Upon discharge, the resident received paperwork that was incomplete, missing several pages, and lacking contact information for the home health agency that was supposed to provide continued care. The social services note indicated that home health services were arranged, but the discharge paperwork given to the resident did not reflect this information. The complainant, who assisted the resident, reported that attempts to contact facility social services for the missing information were unsuccessful. It was not until two weeks after discharge that the complainant received a complete discharge summary via email, which included all required sections and the home health agency's contact information. Additionally, there was a discrepancy in the discharge date communicated to the home health agency, which was told a different date than when the resident actually left the facility. Review of the initial discharge paperwork confirmed that multiple sections were not filled out, pages were missing, and no contact information for the home health agency was provided.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gaithersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wilson Health Care Center | 1.5 mi | ★★★★★ | 10 | 0 |
| Ingleside At King Farm | 4.3 mi | ★★★★★ | 13 | 0 |
| Shady Grove Nursing And Rehabilitation Center | 4.6 mi | ★★★★★ | 34 | 0 |
| Collingswood Rehabilitation And Healthcare Center | 5.8 mi | ★★★★★ | 3 | 0 |
| Sterling Care Rockville Nursing | 6.3 mi | ★★★★★ | 29 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.