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Health Inspection Summary
Shady Grove Nursing and Rehabilitation Center
9701 Medical Center Drive
Rockville, MD 20850
(301) 315-1900
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Deficiency Category
Inspection Date:
1/15/21
Complaint Reporting Period:
5/1/24 - 4/30/25
Inspection Date:
4/12/19
Complaint Reporting Period:
5/1/23 - 4/30/24
Inspection Date:
3/19/18
Complaint Reporting Period:
5/1/22 - 4/30/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies031
Quality of Life and Care Deficiencies635
Infection Control Deficiencies111
Resident Assessment and Care Planning Deficiencies495
Nursing and Physician Services Deficiencies101
Resident Rights Deficiencies155
Nutrition and Dietary Deficiencies011
Pharmacy Service Deficiencies131
Environmental Deficiencies012
Administration Deficiencies011

Detailed result for inspection on 1/15/21
Date of last standard health inspection:1/15/21Read the full report (PDF)
Date(s) of complaint inspection(s) between 5/1/24 - 4/30/25
No complaint inspections
Date(s) of infection control inspection(s) between 5/1/24 - 4/30/25
No infection control inspections
Total number of Health Deficiencies for this nursing home:14
Average number of Health Deficiencies in Maryland:19.3
Average number of Health Deficiencies in the United States:9.6
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide care and assistance to perform activities of daily living for any resident who is unable.

1/15/213/5/21
2 - Minimal harm or potential for actual harm
Few

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

1/15/213/5/21
2 - Minimal harm or potential for actual harm
Some

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

1/15/213/5/21
2 - Minimal harm or potential for actual harm
Few

Provide enough food/fluids to maintain a resident's health.

1/15/213/5/21
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

1/15/213/5/21
2 - Minimal harm or potential for actual harm
Some

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

1/15/213/5/21
2 - Minimal harm or potential for actual harm
Some
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

1/15/213/5/21
2 - Minimal harm or potential for actual harm
Some
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

1/15/213/5/21
2 - Minimal harm or potential for actual harm
Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

1/15/213/5/21
2 - Minimal harm or potential for actual harm
Some

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

1/15/213/5/21
2 - Minimal harm or potential for actual harm
Few

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

1/15/213/5/21
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

1/15/213/5/21
2 - Minimal harm or potential for actual harm
Many
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

1/15/213/5/21
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

1/15/213/5/21
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 4/12/19
Date of last standard health inspection:4/12/19Read the full report (PDF)
Date(s) of complaint inspection(s) between 5/1/23 - 4/30/24
Date(s) of infection control inspection(s) between 5/1/23 - 4/30/24
No infection control inspections
Total number of Health Deficiencies for this nursing home:27
Average number of Health Deficiencies in Maryland:14.5
Average number of Health Deficiencies in the United States:9.5
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

4/12/195/24/19
2 - Minimal harm or potential for actual harm
Few

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

4/12/195/24/19
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

4/12/195/24/19
2 - Minimal harm or potential for actual harm
Few

Provide safe, appropriate pain management for a resident who requires such services.

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

4/12/195/24/19
2 - Minimal harm or potential for actual harm
Many
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

Ensure services provided by the nursing facility meet professional standards of quality.

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

PASARR screening for Mental disorders or Intellectual Disabilities

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

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

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

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

4/12/195/24/19
1 - Potential for minimal harm
Some

Ensure services provided by the nursing facility meet professional standards of quality.

4/12/195/24/19
2 - Minimal harm or potential for actual harm
Few

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

4/12/195/24/19
2 - Minimal harm or potential for actual harm
Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

4/12/195/24/19
2 - Minimal harm or potential for actual harm
Some

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

4/12/195/24/19
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

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

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

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

4/12/195/24/19
2 - Minimal harm or potential for actual harm
Few

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

4/12/195/24/19
1 - Potential for minimal harm
Some

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

4/12/195/24/19
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

4/12/195/24/19
1 - Potential for minimal harm
Many
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure medication error rates are not 5 percent or greater.

4/12/195/24/19
2 - Minimal harm or potential for actual harm
Few

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.

4/12/195/24/19
2 - Minimal harm or potential for actual harm
Few

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.

4/12/195/24/19
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Have enough outside ventilation via a window or mechanical ventilation, or both.

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

4/12/195/24/19
2 - Minimal harm or potential for actual harm
Few

Detailed result for inspection on 3/19/18
Date of last standard health inspection:3/19/18Read the full report (PDF)
Date(s) of complaint inspection(s) between 5/1/22 - 4/30/23
Date(s) of infection control inspection(s) between 5/1/22 - 4/30/23
No infection control inspections
Total number of Health Deficiencies for this nursing home:23
Average number of Health Deficiencies in Maryland:12.1
Average number of Health Deficiencies in the United States:8.8
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

Note: The nursing home is disputing this citation.

3/19/185/18/18
3 - Actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide or obtain dental services for each resident.

3/19/185/18/18
1 - Potential for minimal harm
Some

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

3/19/185/18/18
2 - Minimal harm or potential for actual harm
Few

Provide enough food/fluids to maintain a resident's health.

3/19/185/18/18
2 - Minimal harm or potential for actual harm
Some

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

3/19/186/6/18
1 - Potential for minimal harm
Some

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

3/19/185/18/18
2 - Minimal harm or potential for actual harm
Some
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

3/19/185/18/18
2 - Minimal harm or potential for actual harm
Some
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure each resident receives an accurate assessment.

3/19/185/18/18
1 - Potential for minimal harm
Some

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

3/19/185/18/18
2 - Minimal harm or potential for actual harm
Some

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

3/19/185/18/18
2 - Minimal harm or potential for actual harm
Few

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

3/19/185/18/18
1 - Potential for minimal harm
Some

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

3/19/185/18/18
1 - Potential for minimal harm
Some
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

3/19/185/18/18
2 - Minimal harm or potential for actual harm
Few
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

3/19/185/18/18
2 - Minimal harm or potential for actual harm
Few

Keep residents' personal and medical records private and confidential.

3/19/185/18/18
2 - Minimal harm or potential for actual harm
Some

Allow residents to self-administer drugs if determined clinically appropriate.

3/19/185/18/18
2 - Minimal harm or potential for actual harm
Few

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.

3/19/185/18/18
2 - Minimal harm or potential for actual harm
Few

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.

6/2/227/8/22
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

3/19/185/18/18
2 - Minimal harm or potential for actual harm
Some
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure medication error rates are not 5 percent or greater.

3/19/185/18/18
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

3/19/185/18/18
2 - Minimal harm or potential for actual harm
Few

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

6/2/227/8/22
2 - Minimal harm or potential for actual harm
Few
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

3/19/185/18/18
2 - Minimal harm or potential for actual harm
Some
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

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

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

Provide safe, appropriate pain management for a resident who requires such services.

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

Ensure services provided by the nursing facility meet professional standards of quality.

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

PASARR screening for Mental disorders or Intellectual Disabilities

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

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

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

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

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

Have enough outside ventilation via a window or mechanical ventilation, or both.

3/26/244/29/24
2 - Minimal harm or potential for actual harm
Few

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.

6/2/227/8/22
2 - Minimal harm or potential for actual harm
Few

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

6/2/227/8/22
2 - Minimal harm or potential for actual harm
Few
Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.
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