P&P, Paid & Penalized

Public Medicare data, made visible.

HospitalAdventist Healthcare Shady Grove Medical Center×

Hospital record · FY2026CCN 210057

1Hospital

Adventist Healthcare Shady Grove Medical Center

2Location

Rockville, MD (Maryland’s hospitals on the map and in the table) 20850

Montgomery County

3Type

Not a teaching hospital · 331 beds · Nonprofit · Urban

4Care Compare stars

2 of 5 stars

Overall rating, CMS Care Compare data of July 22, 2026
Open on Care Compare (opens in a new tab)

5Total HAC Score

−0.4582

As CMS reports it

6Payment reduction

N/A

7Estimated cut

$0

Maryland: exempt

Not subject

$0

Maryland’s hospitals are exempt from this program’s cut.

For fiscal year 2026, CMS reports a Total HAC Score of −0.4582 for Adventist Healthcare Shady Grove Medical Center and a payment reduction decision of N/A.

Maryland’s hospitals are scored but not subject to the reduction. The score compares hospitals with each other; it is not a grade of the quality of care.

CMS cut scores of 0.3799 and above.

Each year CMS cuts the hospitals with the highest quarter of scores, those above the 75th percentile, so the line moves with other hospitals’ scores.

highest 2.3133 1% cut Middle hospital: −0.0453 Middle hospital−0.0453 CMS’s line: 0.3799 and up CMS’s line0.3799 and up This hospital: −0.4582 This hospital −0.4582 lowest −1.4728 highest 2.3133 1% cut Middle hospital: −0.0453 Middle hospital−0.0453 CMS’s line: 0.3799 and up CMS’s line0.3799 and up This hospital: −0.4582 This hospital −0.4582

Higher than 22% of the other 2,928 scores CMS published (higher is worse).

CMS’s note on the payment reduction: Maryland hospitals are waived from receiving payment adjustments under the Program.

Where the score came from

CMS scored this hospital on all 6 measures. On every measure a lower value is better. Each row puts the hospital among every hospital with a value: the gray columns are those hospitals, the tall tick is the national median, and the hatched ends score the same as CMS’s floor or cap.

Bringing PSI 90 down to the national median (0.9623) would lower the score the most: by 0.0225, to −0.4807. Try it in the what-if

Figure 1. Of its 6 measures with a value, this hospital is above the national median on 2.
  • This hospital
  • National median
  • Scores the same as CMS’s floor or cap
  1. PSI 90 (what it counts)

    Safety problems such as serious bedsores, falls that break a bone and blood clots after surgery, found by CMS in traditional Medicare claims. A value of 1 matches the national composite value.

    Patient safety and adverse events composite

    Worse than 59% of the other 2,808 hospitals

    estimate

    This site recomputes this measure’s z‑score from CMS’s published value. The recompute can differ from CMS’s z‑score by up to 0.0021. How this site estimates

    CMS value0.9816

    Z-score−0.0477

    Part of score−0.0080

  2. CLABSI (what it counts)

    Bloodstream infections tied to a central line, a tube often placed in a large vein in the neck, chest or groin. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    Central line–associated bloodstream infections

    Worse than 50% of the other 2,181 hospitals

    CMS value0.560

    Z-score−0.1074

    Part of score−0.0179

  3. CAUTI (what it counts)

    Urinary tract infections that start from a urinary catheter, a tube that drains the bladder. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    Catheter-associated urinary tract infections

    Better than 70% of the other 2,354 hospitals

    CMS value0.297

    Z-score−0.6027

    Part of score−0.1005

  4. SSI (what it counts)

    Deep infections at the site of colon surgery or an abdominal hysterectomy, within a month of the operation, pooled into one measure. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    Surgical site infections after colon surgery or abdominal hysterectomy

    Better than 84% of the other 2,269 hospitals

    CMS value0.249

    Z-score−1.0299

    Part of score−0.1717

  5. CDI (what it counts)

    C. diff infections, which cause diarrhea and inflammation of the colon, found by a lab test and starting in the hospital. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    Clostridioides difficile (C. diff) infections

    Better than 56% of the other 2,766 hospitals

    estimate

    This site recomputes this measure’s z‑score from CMS’s published value. The recompute can differ from CMS’s z‑score by up to 0.0071. How this site estimates

    CMS value0.307

    Z-score−0.2734

    Part of score−0.0456

  6. MRSA (what it counts)

    Bloodstream infections with MRSA, a germ that resists several antibiotics, found by a lab test and starting in the hospital. Hospitals report them to the CDC’s National Healthcare Safety Network. A value of 1.0 means as many infections as the CDC’s model predicted.

    MRSA bloodstream infections

    Better than 74% of the other 2,067 hospitals

    CMS value0.368

    Z-score−0.6882

    Part of score−0.1147

Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
MeasureCMS valueNational medianZ-scorePart of the scoreAmong hospitals
PSI 900.98160.9623−0.0477−0.0080Worse than 59% of the other 2,808 hospitals
CLABSI0.5600.559−0.1074−0.0179Worse than 50% of the other 2,181 hospitals
CAUTI0.2970.489−0.6027−0.1005Better than 70% of the other 2,354 hospitals
SSI0.2490.795−1.0299−0.1717Better than 84% of the other 2,269 hospitals
CDI0.3070.346−0.2734−0.0456Better than 56% of the other 2,766 hospitals
MRSA0.3680.641−0.6882−0.1147Better than 74% of the other 2,067 hospitals

How the parts add up

CMS adds the z‑scores and divides by the number of measures scored, so each measure counts the same. Each bar below is one z‑score divided by 6; a bar right of zero raised the score and one left of zero lowered it.

(−0.0477PSI 90−0.1074CLABSI−0.6027CAUTI−1.0299SSI−0.2734CDI−0.6882MRSA)÷6measures=−0.4582Total HAC Score

Added from the rounded z‑scores CMS published, the parts make −0.4582; CMS reports −0.4582. The small difference is rounding.

Figure 2. The parts add up to −0.4582, below CMS’s line.
1% cut PSI 90: z‑score −0.0477 divided by 6 = −0.0080PSI 90−0.0080 CLABSI: z‑score −0.1074 divided by 6 = −0.0179CLABSI−0.0179 CAUTI: z‑score −0.6027 divided by 6 = −0.1005CAUTI−0.1005 SSI: z‑score −1.0299 divided by 6 = −0.1717SSI−0.1717 CDI: z‑score −0.2734 divided by 6 = −0.0456CDI−0.0456 MRSA: z‑score −0.6882 divided by 6 = −0.1147MRSA−0.1147 Total HAC Score: −0.4582Score−0.4582 CMS’s line: between 0.3792 and 0.3799 CMS’s line −0.6−0.4−0.20.00.20.4 1% cut PSI 90: z‑score −0.0477 divided by 6 = −0.0080PSI 90−0.0080 CLABSI: z‑score −0.1074 divided by 6 = −0.0179CLABSI−0.0179 CAUTI: z‑score −0.6027 divided by 6 = −0.1005CAUTI−0.1005 SSI: z‑score −1.0299 divided by 6 = −0.1717SSI−0.1717 CDI: z‑score −0.2734 divided by 6 = −0.0456CDI−0.0456 MRSA: z‑score −0.6882 divided by 6 = −0.1147MRSA−0.1147 Total HAC Score: −0.4582Score−0.4582 CMS’s line: between 0.3792 and 0.3799 CMS’s line −0.6−0.4−0.20.00.20.4

This site recomputes · Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
MeasureZ-scorePart of the scoreRunning total
PSI 90−0.0477−0.0080−0.0080
CLABSI−0.1074−0.0179−0.0259
CAUTI−0.6027−0.1005−0.1264
SSI−1.0299−0.1717−0.2981
CDI−0.2734−0.0456−0.3437
MRSA−0.6882−0.1147−0.4584
Total HAC Score−0.4582
CMS’s line0.37920.3799

What if a measure were different?

Change a measure’s value to see how this site recomputes the Total HAC Score and the payment reduction decision, starting from CMS’s values.

The what-if needs JavaScript. Without it, the values below stay as they are.

Show table
CMS reportsHypothetical
Total HAC Score−0.4582same
Payment reduction decisionN/A (not subject to the reduction)same

CMS reports a Total HAC Score of −0.4582 and a payment reduction decision of N/A (not subject to the reduction).

A what-if shows the formula’s arithmetic, not what a hospital could realistically change or how. CMS’s real result also depends on other hospitals.

Each measure weighs 1 ÷ 6 of the score.

Measure values

SIR 1.0 = as many infections as predicted · Lower is better

On each track the tick is the national median; shaded values score the same as the floor or cap, as this site fits them to CMS’s values.

CMS 0.9816 · median 0.9623 · floor 0.7760 · cap 1.3482 · each 0.1 = 0.1164

CMS 0.560 · median 0.559 · cap 1.572 · each 0.1 = 0.0387

CMS 0.297 · median 0.489 · cap 1.537 · each 0.1 = 0.0402

CMS 0.249 · median 0.795 · cap 2.118 · each 0.1 = 0.0286

CMS 0.307 · median 0.346 · cap 0.944 · each 0.1 = 0.0645

CMS 0.368 · median 0.641 · cap 1.762 · each 0.1 = 0.0348

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Figure 3. Each bar is one measure’s part of this hospital’s Total HAC Score of −0.4582: its z‑score divided by 6, the number of measures scored.
  • PSI 90 −0.0080
  • CLABSI −0.0179
  • CAUTI −0.1005
  • SSI −0.1717
  • CDI −0.0456
  • MRSA −0.1147

A measure adds its z‑score divided by 6, the number of measures scored. Bars right of the center line raise the score. Hatched: assigned by CMS.

This site recomputes · Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
MeasureZ-scorePart of the scoreHypothetical
PSI 90−0.0477−0.0080same
CLABSI−0.1074−0.0179same
CAUTI−0.6027−0.1005same
SSI−1.0299−0.1717same
CDI−0.2734−0.0456same
MRSA−0.6882−0.1147same

Among hospitals with a Yes or No payment decision, CMS cut those with a published Total HAC Score of 0.3799 or higher and none at 0.3792 or lower. Maryland’s hospitals are scored but not subject to the reduction.

Held fixed: every other hospital’s results, CMS’s line, and each measure’s mean, spread, floor and cap as this site fits them to CMS’s published values.

Its infections, year by year

This hospital’s infection rate against prediction for each calendar year Care Compare published one, on each measure with at least two years of results (black), over the nation’s middle hospital (gray). Below the dashed line at one, fewer infections than predicted. Each year is measured against the same fixed baseline, not against other hospitals, so unlike the score they can all improve at once.

Figure 4. 5 of its 5 infection measures ended lower than they started.
CLABSI 0.62 → 0.36 1as predicted 0 ’18’21’24 Nation’s middle CLABSI, 2017: 0.617CLABSI, 2018: 0.405CLABSI, 2019: 0.377CLABSI, 2021: 0.983CLABSI, 2022: 1.279CLABSI, 2023: 0.784CLABSI, 2024: 0.357 CAUTI 0.31 → 0.26 1 0 ’18’21’24 CAUTI, 2017: 0.314CAUTI, 2018: 1.729CAUTI, 2019: 0.675CAUTI, 2021: 2.285CAUTI, 2022: 0.422CAUTI, 2023: 0.351CAUTI, 2024: 0.258 SSI, colon 1.22 → 0.00 1 0 ’18’21’24 SSI, colon, 2017: 1.217SSI, colon, 2018: 0.269SSI, colon, 2019: 1.128SSI, colon, 2021: 0.000SSI, colon, 2022: 1.850SSI, colon, 2023: 0.599SSI, colon, 2024: 0.000 MRSA 1.76 → 0.43 1 0 ’18’21’24 MRSA, 2017: 1.760MRSA, 2018: 0.845MRSA, 2019: 0.421MRSA, 2021: 0.589MRSA, 2022: 0.264MRSA, 2023: 0.301MRSA, 2024: 0.431 C. diff 1.21 → 0.34 1 0 ’18’21’24 C. diff, 2017: 1.212C. diff, 2018: 0.501C. diff, 2019: 0.682C. diff, 2021: 0.669C. diff, 2022: 0.446C. diff, 2023: 0.267C. diff, 2024: 0.345 CLABSI 0.62 → 0.36 1as predicted 0 ’18’20’22’24 Nation’s middle CLABSI, 2017: 0.617CLABSI, 2018: 0.405CLABSI, 2019: 0.377CLABSI, 2021: 0.983CLABSI, 2022: 1.279CLABSI, 2023: 0.784CLABSI, 2024: 0.357 CAUTI 0.31 → 0.26 1 0 ’18’20’22’24 CAUTI, 2017: 0.314CAUTI, 2018: 1.729CAUTI, 2019: 0.675CAUTI, 2021: 2.285CAUTI, 2022: 0.422CAUTI, 2023: 0.351CAUTI, 2024: 0.258 SSI, colon 1.22 → 0.00 1 0 ’18’20’22’24 SSI, colon, 2017: 1.217SSI, colon, 2018: 0.269SSI, colon, 2019: 1.128SSI, colon, 2021: 0.000SSI, colon, 2022: 1.850SSI, colon, 2023: 0.599SSI, colon, 2024: 0.000 MRSA 1.76 → 0.43 1 0 ’18’20’22’24 MRSA, 2017: 1.760MRSA, 2018: 0.845MRSA, 2019: 0.421MRSA, 2021: 0.589MRSA, 2022: 0.264MRSA, 2023: 0.301MRSA, 2024: 0.431 C. diff 1.21 → 0.34 1 0 ’18’20’22’24 C. diff, 2017: 1.212C. diff, 2018: 0.501C. diff, 2019: 0.682C. diff, 2021: 0.669C. diff, 2022: 0.446C. diff, 2023: 0.267C. diff, 2024: 0.345

Source: CMS Care Compare, healthcare-associated infections by hospital, calendar years 2017 to 2024 (Provider Data Catalog archives; the oldest year through the Internet Archive’s copy).

Show table
Calendar yearCLABSICAUTISSI, colonMRSAC. diff
20170.6170.3141.2171.7601.212
20180.4051.7290.2690.8450.501
20190.3770.6751.1280.4210.682
20210.9832.2850.0000.5890.669
20221.2790.4221.8500.2640.446
20230.7840.3510.5990.3010.267
20240.3570.2580.0000.4310.345

Among hospitals like it

Each row is a group this hospital belongs to, drawn from every hospital in it with a payment decision. Red columns are hospitals past CMS’s line, the ones CMS cut; the short tick is the group’s middle score.

Figure 5. Its score is below the middle in all 6 groups it belongs to; the share cut runs from 22% (300 to 499 beds) to 26% (Nonprofit).
All hospitals: CMS cut 718 of 2,886 (25%); middle score −0.0453All hospitals 2,886 hospitals25% cut South region: CMS cut 263 of 1,174 (22%); middle score −0.1056South region 1,174 hospitals22% cut Not teaching: CMS cut 389 of 1,563 (25%); middle score −0.1053Not teaching 1,563 hospitals25% cut 300 to 499 beds: CMS cut 113 of 523 (22%); middle score −0.0384300 to 499 beds 523 hospitals22% cut Nonprofit: CMS cut 478 of 1,830 (26%); middle score −0.0134Nonprofit 1,830 hospitals26% cut Urban: CMS cut 510 of 2,241 (23%); middle score −0.0574Urban 2,241 hospitals23% cut CMS’s line: between 0.3792 and 0.3799 CMS’s line −1012 This hospital: −0.4582 This hospital −0.4582 All hospitals: CMS cut 718 of 2,886 (25%); middle score −0.0453All hospitals2,886 hospitals25% cut South region: CMS cut 263 of 1,174 (22%); middle score −0.1056South region1,174 hospitals22% cut Not teaching: CMS cut 389 of 1,563 (25%); middle score −0.1053Not teaching1,563 hospitals25% cut 300 to 499 beds: CMS cut 113 of 523 (22%); middle score −0.0384300 to 499 beds523 hospitals22% cut Nonprofit: CMS cut 478 of 1,830 (26%); middle score −0.0134Nonprofit1,830 hospitals26% cut Urban: CMS cut 510 of 2,241 (23%); middle score −0.0574Urban2,241 hospitals23% cut CMS’s line: between 0.3792 and 0.3799 CMS’s line −1.5−1.0−0.50.00.51.01.52.0 This hospital: −0.4582 This hospital −0.4582

Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
GroupWith a decisionHospitals cutShare cutMiddle scoreHospital higher than
All hospitals2,88671825%−0.045322%
South region1,17426322%−0.105625%
Not teaching1,56338925%−0.105327%
300 to 499 beds52311322%−0.038416%
Nonprofit1,83047826%−0.013419%
Urban2,24151023%−0.057421%
This hospital−0.4582
CMS’s line0.37920.3799

The nearest hospitals

The 8 closest hospitals with a Total HAC Score, in a straight line. The squares are each hospital’s measures in order: filled, above the national median; open, at or below it; hatched, assigned by CMS; blank, not scored.

Figure 6. CMS cut none of the 8 nearest hospitals; the closest is 6 miles away.
5 mi10 mi8. MedStar Georgetown University Hospital, Washington: score 0.0306, not cut, 14 miles87. Reston Hospital Center, Reston: score −0.8292, not cut, 13 miles76. Sibley Memorial Hospital, Washington: score 0.0558, not cut, 12 miles65. Adventist Healthcare White Oak Medical Center, Silver Spring: score −0.2079, not subject, 12 miles54. Holy Cross Hospital, Silver Spring: score 0.4640, not subject, 10 miles43. MedStar Montgomery Medical Center, Olney: score −0.6614, not subject, 9 miles32. Suburban Hospital, Bethesda: score 0.7745, not subject, 8 miles21. Holy Cross Germantown Hospital, Germantown: score 0.3579, not subject, 6 miles1This hospital: Adventist Healthcare Shady Grove Medical Center

Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.

Show table
HospitalMilesScoreDecision
Holy Cross Germantown Hospital, Germantown, MD60.3579not subject
Suburban Hospital, Bethesda, MD80.7745not subject
MedStar Montgomery Medical Center, Olney, MD9−0.6614not subject
Holy Cross Hospital, Silver Spring, MD100.4640not subject
Adventist Healthcare White Oak Medical Center, Silver Spring, MD12−0.2079not subject
Sibley Memorial Hospital, Washington, DC120.0558not cut
Reston Hospital Center, Reston, VA13−0.8292not cut
MedStar Georgetown University Hospital, Washington, DC140.0306not cut

#HospitalMilesScoreDecisionEst. cut ($, modeled)Measures
1Holy Cross Germantown HospitalGermantown, MD60.3579N/A$0Above the national median on 4 of 6 measures
2Suburban HospitalBethesda, MD80.7745N/A$0Above the national median on 5 of 6 measures
3MedStar Montgomery Medical CenterOlney, MD9−0.6614N/A$0Above the national median on 2 of 6 measures
4Holy Cross HospitalSilver Spring, MD100.4640N/A$0Above the national median on 5 of 6 measures
5Adventist Healthcare White Oak Medical CenterSilver Spring, MD12−0.2079N/A$0Above the national median on 2 of 6 measures
6Sibley Memorial HospitalWashington, DC120.0558No cut$0Above the national median on 5 of 6 measures
7Reston Hospital CenterReston, VA13−0.8292No cut$0Above the national median on 1 of 6 measures
8MedStar Georgetown University HospitalWashington, DC140.0306No cut$0Above the national median on 3 of 6 measures

CMS’s footnotes on this page

a
Maryland hospitals are waived from receiving payment adjustments under the Program.

A penalty reflects how CMS’s formula scored relative performance; it is not a verdict on the quality of care.

Cite this page

Paid & Penalized. Adventist Healthcare Shady Grove Medical Center, Rockville, MD: Hospital-Acquired Conditions, FY2026. https://paidandpenalized.org/hacrp/hospital/210057/. Source: CMS Provider Data Catalog, HACRP FY2026 (yq43-i98g), released August 13, 2026.