Montgomery Village Care Center
19301 Watkins Mill Road, Gaithersburg, MD 20879 · Montgomery County · 147 certified beds · avg 162 residents/day · certified since Mar 14, 1995
5/5
Health inspection rating (on-site)
0
Serious findings on record
$0
Fines, last 3 years
3.08
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★★5/5 · CMS overall rating: 5/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (39)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 16, 2025 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint |
| Apr 16, 2025 | D · Potential for harm, one-off | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. · from a complaint |
| Jan 28, 2021 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Jan 28, 2021 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Apr 29, 2019 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Apr 29, 2019 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Apr 29, 2019 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 29, 2019 | E · Potential for harm, repeated | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Apr 29, 2019 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Apr 29, 2019 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Apr 29, 2019 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Apr 29, 2019 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Apr 29, 2019 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Apr 29, 2019 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 29, 2019 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Apr 29, 2019 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Apr 29, 2019 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Apr 29, 2019 | C · Minimal risk, facility-wide | The facility has more than 120 beds but did not hire a qualified full-time social worker as required. |
| Apr 29, 2019 | B · Minimal risk, repeated | The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule. |
| Apr 29, 2019 | B · Minimal risk, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 30, 2018 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Apr 30, 2018 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Apr 30, 2018 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Apr 30, 2018 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 30, 2018 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Apr 30, 2018 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 30, 2018 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Apr 30, 2018 | C · Minimal risk, facility-wide | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Apr 30, 2018 | C · Minimal risk, facility-wide | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. |
| Apr 30, 2018 | C · Minimal risk, facility-wide | The facility did not designate a physician to serve as medical director — the doctor responsible for overseeing resident care policies and coordinating medical care across the facility. |
| Apr 30, 2018 | C · Minimal risk, facility-wide | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Apr 30, 2018 | C · Minimal risk, facility-wide | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Apr 30, 2018 | B · Minimal risk, repeated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Apr 30, 2018 | B · Minimal risk, repeated | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Apr 30, 2018 | B · Minimal risk, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Apr 30, 2018 | B · Minimal risk, repeated | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Apr 30, 2018 | B · Minimal risk, repeated | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Apr 30, 2018 | B · Minimal risk, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Apr 30, 2018 | B · Minimal risk, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (16 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2018 | 19 | 0 | F |
| 2019 | 16 | 0 | E |
| 2021 | 2 | 0 | D |
| 2025 | 2 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Maryland avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.08 | 3.83 | 3.95 | bottom 12% in Maryland; bottom 17% in the U.S. |
| Registered Nurse hours | 0.81 | 0.83 | 0.69 | top 33% in Maryland; top 26% in the U.S. |
| Weekend total nurse staffing | 2.78 | 3.43 | 3.50 | bottom 13% in Maryland; bottom 20% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.68 | 0.63 | 0.48 | top 28% in Maryland; top 17% in the U.S. |
| Total nursing staff turnover (%) | 22.9 | 40.2 | 45.8 | top 10% in Maryland; top 5% in the U.S. |
| RN turnover (%) | 30.0 | 38.7 | 42.9 | top 29% in Maryland; top 29% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.59, RN 0.95, weekend 3.23. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Green, Dov | Individual | 5% or Greater Indirect Ownership Interest | — | 03/01/2022 |
| Mermelstein, Boruch | Individual | 5% or Greater Indirect Ownership Interest | — | 03/01/2022 |
| Montgomery Operator Holdco, LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 03/01/2022 |
| Zager, Nachum | Individual | 5% or Greater Indirect Ownership Interest | — | 03/01/2022 |
| Lofton, Christopher | Individual | W-2 Managing Employee | NOT APPLICABLE | 03/01/2022 |
| Stern, Samuel | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prepare residents and families for discharge, and what support do you arrange for after they leave?"
- "What exactly do you hand off to the next provider when a resident is discharged, and how do you confirm they received it?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Wilson Health Care Center | 1.6 mi | Gaithersburg, MD | ★★★★★ | 5/5 | |
| Ingleside at King Farm | 4.3 mi | Rockville, MD | ★★★★★ | 4/5 | |
| Shady Grove Nursing and Rehabilitation Center | 4.6 mi | Rockville, MD | ★★☆☆☆ | 1/5 | |
| Collingswood Rehabilitation and Healthcare Center | 5.8 mi | Rockville, MD | ★★☆☆☆ | 2/5 | |
| Sterling Care Rockville Nursing | 6.3 mi | Rockville, MD | ★★★★☆ | 3/5 | |
| The Village at Rockville | 6.3 mi | Rockville, MD | ★★★☆☆ | 3/5 | |
| Potomac Valley Rehabilitation and Healthcare | 7.0 mi | Rockville, MD | ★★★☆☆ | 2/5 | |
| Bedford Court Healthcare Cent. | 8.6 mi | Silver Spring, MD | ★★★★★ | 4/5 | |
| Hebrew Home of Greater Washington | 9.2 mi | Rockville, MD | ★★★★★ | 4/5 | |
| Brooke Grove Rehab. & Nsg Ctr | 9.3 mi | Sandy Spring, MD | ★★☆☆☆ | 2/5 | |
| Montcare at Potomac | 9.4 mi | Potomac, MD | ★★★★★ | 4/5 | |
| Layhill Nursing and Rehabilitation Center | 9.6 mi | Silver Spring, MD | ★☆☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 215272.