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Health Inspection Summary
Montgomery Village Care Center
19301 Watkins Mill Road
Gaithersburg, MD 20879
(301) 527-2500
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Deficiency Category
Inspection Date:
1/28/21
Complaint Reporting Period:
5/1/24 - 4/30/25
Inspection Date:
4/29/19
Complaint Reporting Period:
5/1/23 - 4/30/24
Inspection Date:
4/30/18
Complaint Reporting Period:
5/1/22 - 4/30/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies000
Quality of Life and Care Deficiencies042
Infection Control Deficiencies001
Resident Assessment and Care Planning Deficiencies144
Nursing and Physician Services Deficiencies013
Resident Rights Deficiencies134
Nutrition and Dietary Deficiencies000
Pharmacy Service Deficiencies022
Environmental Deficiencies000
Administration Deficiencies023

Detailed result for inspection on 1/28/21
Date of last standard health inspection:1/28/21Read 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:2
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
No Quality of Life and Care Deficiencies were found during this inspection period.
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
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)

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

1/28/212/17/21
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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

1/28/212/17/21
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
No Pharmacy Service Deficiencies were found during this inspection period.
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 4/29/19
Date of last standard health inspection:4/29/19Read the full report (PDF)
Date(s) of complaint inspection(s) between 5/1/23 - 4/30/24
No complaint inspections
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:16
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
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 safe, appropriate pain management for a resident who requires such services.

4/29/196/12/19
2 - Minimal harm or potential for actual harm
Few

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

4/29/196/12/19
2 - Minimal harm or potential for actual harm
Some

Assist a resident in gaining access to vision and hearing services.

4/29/196/12/19
2 - Minimal harm or potential for actual harm
Few

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

4/29/196/12/19
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
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.

4/29/196/12/19
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.

4/29/196/12/19
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.

4/29/196/12/19
2 - Minimal harm or potential for actual harm
Some

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

4/29/196/12/19
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 the resident and his/her doctor meet face-to-face at all required visits.

4/29/196/12/19
1 - Potential for minimal harm
Some
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 and the facility must promote and facilitate resident self-determination through support of resident choice.

4/29/196/12/19
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.

4/29/196/12/19
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.

4/29/196/12/19
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)

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.

4/29/196/12/19
1 - Potential for minimal harm
Some

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.

4/29/196/12/19
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
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)

Hire a qualified full-time social worker in a facility with more than 120 beds.

4/29/196/12/19
1 - Potential for minimal harm
Many

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

4/29/196/12/19
2 - Minimal harm or potential for actual harm
Some

Detailed result for inspection on 4/30/18
Date of last standard health inspection:4/30/18Read the full report (PDF)
Date(s) of complaint inspection(s) between 5/1/22 - 4/30/23
No complaint inspections
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:19
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
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 appropriate treatment and care according to orders, resident’s preferences and goals.

4/30/186/8/18
2 - Minimal harm or potential for actual harm
Few

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

4/30/186/8/18
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.

4/30/186/8/18
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)

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

4/30/186/8/18
1 - Potential for minimal harm
Some

Ensure each resident receives an accurate assessment.

4/30/186/8/18
1 - Potential for minimal harm
Some

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

4/30/186/8/18
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.

4/30/186/8/18
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)

Observe each nurse aide's job performance and give regular training.

4/30/186/8/18
1 - Potential for minimal harm
Many

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

4/30/186/8/18
1 - Potential for minimal harm
Many

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

4/30/186/8/18
1 - Potential for minimal 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)

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

4/30/186/8/18
1 - Potential for minimal harm
Some

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.

4/30/186/8/18
1 - Potential for minimal harm
Some

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

4/30/186/8/18
1 - Potential for minimal harm
Some

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.

4/30/186/8/18
1 - Potential for minimal harm
Some
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)

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.

4/30/186/8/18
2 - Minimal harm or potential for actual harm
Some

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

4/30/186/8/18
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
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)

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

4/30/186/8/18
1 - Potential for minimal harm
Many

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.

4/30/186/8/18
1 - Potential for minimal harm
Many

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

4/30/186/8/18
2 - Minimal harm or potential for actual harm
Many
Complaints and facility-reported incidents in the past 3 years
This nursing home has not been cited for any deficiencies from incidents reported by the nursing home or complaints in the last 3 years.
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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