Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carriage Hill Bethesda during CMS and state inspections, most recent first.
A resident who was cognitively intact, as evidenced by a BIMS score of 14, had previously told facility staff that he/she did not want to apply for Medicaid and planned to return home. Despite this, facility leadership and the business office submitted a Medicaid application without the resident's knowledge or consent, designating the case as an applicant without a representative who lacked capacity to appoint one. This misrepresented the resident's decision-making capacity and failed to honor the resident's right to refuse services and direct his/her own personal and financial affairs.
Pharmaceutical services failed to verify correct indications for antiepileptic medications prescribed to a resident. The MAR listed Depakote for seizures and Lamotrigine for epilepsy, yet review of the medical record showed no history or current diagnosis of seizures or epilepsy. A staff member confirmed the absence of such diagnoses in the chart and could not explain how the facility or pharmacy ensured that the indications documented for these medications were accurate.
A resident’s MAR and physician orders showed that acetaminophen was administered in amounts exceeding the ordered 3 g/24 hr maximum when both scheduled and PRN doses were given on the same days. The same resident had PRN orders for oxycodone 5 mg q6h for mild to moderate pain and oxycodone 7.5 mg q6h for severe pain rated 7–10, yet received oxycodone 7.5 mg doses before the 6‑hour interval elapsed and for pain scores below the ordered severity range. Facility staff, upon review with surveyors, acknowledged these administrations as medication errors.
A resident was found to lack access to both a phone and a working TV remote in a semi-private room. Staff confirmed there was only one phone jack in the room, with the single phone line connected to the roommate’s phone, and that the resident did not have a personal or facility-provided phone. Staff reported the resident sometimes used the roommate’s phone for private communication with family. During observation, the Maintenance Director was unable to operate the TV with the resident’s remote and had to turn the TV on manually, confirming the remote was not functioning.
Call lights were left out of reach for 3 residents during survey observations. One resident had a call light on the floor, and two other residents had call bells on the floor or hanging from the bed and out of reach while both complained of pain. An LPN retrieved the call bells and placed them within reach after the surveyor notified staff.
Restricted visiting hours were posted at the entrance, stating visitors were only allowed during set times each day and on holidays. The Administrator said residents could have visitors at any time, but multiple residents said the posted hours matched current practice. An RCP stated the sign was placed on the door each evening, removed in the morning, and the front entrance was locked after 8:00 PM; a side doorbell was available, but there was no signage directing visitors to it.
Grievance Process and Follow-Up Deficiencies: Surveyors found that blank grievance forms were not posted or readily available in visible areas, and residents were unaware of how to access the grievance process or submit concerns anonymously. Record review showed the prior grievance system relied on SW staff to initiate forms, with no documented grievance resolution statements returned to residents. In addition, a resident’s complaint about rough wheelchair transport was raised in Resident Council, but the NHA confirmed no follow-up was completed.
A resident received Seroquel 75 mg HS, but the charted indication was only "psychotic symptoms," which did not identify a specific diagnosed condition to support antipsychotic use. The psych NP stated the EMR indication had been entered incorrectly.
Delayed Reporting of Alleged Abuse Incident: A resident alleged that an RN/LPN wound nurse hit them on the back during a wound assessment, and the resident and family heard the resident ask, "Why did you hit me?" Staff did not respond and left the room. Although the facility said it became aware of the incident around 1 PM, the report to OHCQ was not made until 3:16 PM, exceeding the 2-hour reporting requirement.
Failure to provide a replacement meal after breakfast was not consumed. A resident with cognitive impairment and recent weight loss was observed away from the room while the breakfast tray remained untouched and the plate was found on the floor with oatmeal and eggs spilled. The DON was notified and housekeeping cleaned the spill, but there was no evidence the resident was assessed for intake or offered a replacement tray, substitute meal, or nutritional supplement. The CDM said no extra breakfast tray was requested, and an RN stated she was unaware the resident needed a replacement meal.
A consultant pharmacist failed to identify and report an irregularity during the monthly med regimen review for a resident receiving Seroquel. The order listed a nonspecific indication of "psychotic symptoms," which did not reflect a diagnosed clinical condition or an appropriate indication for the antipsychotic. An NP stated the indication had been entered incorrectly in the EMR, but there was no evidence the pharmacist documented or reported the issue during the review.
A resident had duplicate Colace orders in the chart, and the MAR showed repeated administrations that matched the duplicated directions. During review with the surveyor, an LPN agreed the orders were duplicated and the medication was given in error.
Unsafe Food Storage and Sanitation Practices: Surveyors observed multiple food safety breaches in the dietary dept, including pre-poured syrup containers on a soiled table without labels or dates, an open and unlabeled salad dressing container in the walk-in refrigerator, opened bread products without labeling or dating, and multiple unlabeled dry storage items. They also noted food debris and liquid on the kitchen floor, ice buildup in the walk-in freezer, a spill on refrigerator shelving, and an incomplete 3-compartment sink sanitation log; the CDM acknowledged the findings.
The facility failed to maintain infection control practices in linen storage and laundry areas. Soiled linen was stored in the same room as clean linen, with three trash cans of soiled linen and two carts of clean linen observed together in a room labeled bath. In the laundry service area, staff personal items were found on folding tables, personal lockers were not being used, and staff belongings including food and drinks were present in two areas.
Pest control failure with ants in resident rooms. During survey rounds, residents reported ants in their rooms and said the issue had already been reported to maintenance, but it remained unresolved. Staff said concerns were entered into the TELS work order system, yet ants were still observed in multiple rooms on the 1st floor on follow-up rounds, including on a bag on a resident’s nightstand and along a window sill.
Missing Annual Abuse, Neglect, and Exploitation Training for PRN and Part-Time GNAs: The facility failed to show evidence that part-time and PRN GNAs received annual training on abuse prevention, neglect, and exploitation. Review of GNA files found 7 of 8 records without the required annual education, and the ADON and HR director stated that these staff were not required to demonstrate compliance with the annual clinical training requirements.
Failure to ensure annual clinical training for PRN and part-time GNAs. The ADON stated that full-time GNA staff were tracked for annual competency training, but PRN and part-time GNAs were not required to meet the same annual clinical education requirements. Review of HR and education records showed 7 of 8 PRN or part-time GNA files lacked evidence of the required 12 hours of annual clinical training, and the DON and ADON agreed these staff were not being held to the same standard as full-time staff.
The facility failed to complete and transmit MDS assessments for 27 residents within the required timeframe. The delay was due to increased admissions and a reduction in staff responsible for MDS assessments. The facility prioritized Medicare assessments, leading to delays in others. The issue was acknowledged by the Lead MDS Coordinator and reported to the NHA and DON.
The facility failed to maintain safe hot water temperatures, with several resident bathroom sinks exceeding the maximum allowable limit. Despite weekly monitoring and a mixing valve set at 118 degrees Fahrenheit, temperatures were recorded as high as 128.2 degrees Fahrenheit. The Maintenance Director could not explain the discrepancy, posing a potential risk to all residents.
The facility failed to ensure a homelike environment and accommodate resident needs, as observed by surveyors. Environmental concerns such as stained ceiling tiles, missing call bell cords, and a covered smoke detector were noted. Additionally, a resident experienced discomfort due to an air mattress not ordered by a physician, which was not promptly addressed despite complaints.
The facility failed to complete MDS assessments within the required timeframe for six residents, with some assessments being over 30 days overdue. The Lead MDS Coordinator cited increased admissions and reduced staffing as reasons for the delay. The NHA and DON were informed of these findings.
The facility did not complete Quarterly MDS assessments within the required timeframe for 18 residents. The delay was due to increased admissions and a reduction in staff responsible for assessments, leaving only the Lead MDS Coordinator and an LPN to handle the workload. The NHA and DON were informed of the issue.
The facility failed to provide invitations and conduct care plan meetings for several residents, leading to deficiencies in care plan documentation and updates. A resident with moderate cognitive impairment was not invited to meetings, and another resident's care plan was not updated to reflect current dialysis access. Additionally, two residents had only one documented care plan meeting over extended periods, with the facility acknowledging the lack of documentation and late status of meetings.
The facility failed to maintain accurate medical records and documentation for several residents, including discrepancies in activity participation records, medication administration, and Medical Orders for Life-Sustaining Treatment (MOLST) forms. A resident did not receive prescribed medication for ten days, and another was observed without the ordered air mattress. Additionally, MOLST forms inaccurately reflected residents' cognitive statuses.
A resident was neglected during an entire shift, resulting in soaked bed linens and significant distress. The resident's call light was on, and they expressed a need to be cleaned. The night shift staff found the resident in this condition, indicating neglect during the evening shift. An LPN documented the incident, and the Director of Nursing acknowledged awareness of the situation.
A facility failed to thoroughly investigate an abuse allegation involving a resident who was reportedly hit by a GNA. Despite interviews with the resident, staff, and other residents, the facility did not obtain a statement from the alleged perpetrator, which was a critical oversight in the investigation process.
The facility failed to uphold resident dignity and staff identification protocols. A GNA entered a resident's room without knocking, and another GNA was observed without a visible name badge. Both staff members acknowledged the expectations and their lapses. These incidents were reported to the NHA and DON.
A facility failed to accurately code a resident's discharge status on the MDS assessment. The resident was discharged to another nursing home, but the MDS incorrectly recorded the discharge as to a short-term general hospital. This error was confirmed by the Social Worker Director, an LPN, and the Lead MDS Coordinator, who acknowledged the need for correction. The NHA was informed of the inaccuracy.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific health needs. A resident experienced unmanaged constipation, another had no care plan for IV hydration despite IBS-related diarrhea, and a third lacked a care plan for ADL support despite being dependent on staff. These oversights were confirmed by facility staff.
A resident with documented preferences for various activities was frequently observed sitting inactive in a hallway, indicating a failure by facility staff to provide a personalized and ongoing activities program. Despite the resident's care plan requiring participation in activities 3-5 times weekly, minimal engagement was documented, and staff interviews confirmed limited activity involvement.
A facility failed to schedule a neurology consultation for a resident with New Onset Seizure, despite hospital discharge instructions and progress notes from physicians and nurse practitioners indicating the need for follow-up. Staff interviews revealed a lack of clarity in the appointment scheduling process, and the Medical Director acknowledged the oversight, noting the resident's stability on medication.
A facility failed to adhere to its respiratory care protocols for a resident requiring oxygen therapy. The surveyor observed that the oxygen humidifier bottle and tubing were not dated, and there was no oxygen usage sign on the resident's door. The facility's policy required these measures, and the DON acknowledged the oversight.
A facility failed to discontinue a medication in a timely manner for a resident with cognitive and psychiatric diagnoses. Despite a pharmacist's recommendation and a physician's order to discontinue Oxycodone PRN due to non-use, the medication was not discontinued until two months later. The DON confirmed the oversight during an interview, highlighting a lapse in following the process for pharmacy recommendations.
A resident with severe malnutrition and encephalopathy reported a painful dental issue upon admission, but the facility failed to provide prompt dental care. An initial assessment identified a broken tooth, but it was later altered to indicate no issues, and the resident was not referred for dental services. The administrator acknowledged the oversight.
The facility failed to provide meals according to the dietary preferences and needs of three residents, leading to deficiencies in food service. A resident received incorrect breakfast trays missing items like biscuits and coffee, while another resident on a gluten-free diet received unsuitable food. A third resident experienced issues with incorrect meal trays, resulting in missed meals. The Dietary Manager cited understaffing as a reason for delayed updates to dietary preferences.
The facility failed to meet the dietary needs of two residents. One resident did not receive the prescribed low-fat, low-residue diet, and the facility could not verify the initial diet order. Another resident was not provided with a lunch meal on dialysis days, despite leaving the facility after breakfast and returning in the afternoon. The facility did not ensure the resident had a meal during dialysis, and the meal tray was left on the food delivery cart.
Resident Rights Violated by Unauthorized Medicaid Application Submission
Penalty
Summary
The facility failed to honor a resident's right to make his/her own decisions regarding personal and financial affairs, including the right to refuse services, by submitting a Medicaid application without the resident's knowledge or consent. During an interview, the resident and the resident's daughter reported that the resident had previously informed the social worker that he/she did not want to apply for Medicaid and intended to return home. Despite this expressed wish, the facility proceeded to submit a Medicaid application on the resident's behalf, and the resident stated not knowing how the facility could do that without his/her information and permission. The Administrator confirmed in an interview that a Medicaid application had been submitted for the resident and stated it was done to help him/her. The Business Office Manager reported she had been advised by the facility that it was acceptable to submit the Medicaid application on the resident's behalf. Review of the Medicaid application showed it was completed under the designation "applicant without representative who lacks capacity to appoint a representative." However, review of the medical record revealed the resident had a BIMS score of 14, indicating he/she was cognitively intact and capable of making his/her own decisions. These findings show the facility inaccurately represented the resident's decision-making capacity while submitting the application without consent.
Incorrect Medication Indications Not Verified for Antiepileptic Drugs
Penalty
Summary
Surveyors identified that pharmaceutical services failed to ensure accurate indications for medications prescribed and administered to a resident. Review of the resident’s March 2026 MAR showed physician orders for Depakote 250 mg twice daily for seizures and Lamotrigine 25 mg, four tablets once daily, for epilepsy. Further review of the resident’s medical record revealed no history or current diagnosis of seizures or epilepsy to support these indications. In an interview, a staff member confirmed that the resident did not have epilepsy or seizures and that there was nothing in the medical file indicating any history of these conditions, and was unable to explain how the facility or pharmacy verified that the indications listed for these medications were correct.
Medication Administration Errors With Acetaminophen and Oxycodone
Penalty
Summary
Surveyors identified a deficiency in medication administration for one resident when review of the medical record and MARs showed that acetaminophen was given in excess of the ordered maximum daily dose. The physician had ordered acetaminophen 500 mg, two tablets by mouth every 8 hours as needed for moderate pain, with a directive not to exceed 3 g in 24 hours, and a separate order for Tylenol Extra Strength 500 mg, two tablets by mouth three times a day for pain. Review of the March MAR showed that on two dates the resident received both the scheduled three-times-daily acetaminophen and additional PRN acetaminophen, totaling 4,000 mg in 24 hours, which exceeded the 3,000 mg limit specified in the order. During interview, facility staff reviewed the MAR with the surveyor and acknowledged that the resident received more than 3 g of acetaminophen on those dates. Further review of the same resident’s record showed physician orders for oxycodone 5 mg by mouth every 6 hours as needed for mild to moderate pain, and oxycodone 7.5 mg by mouth every 6 hours as needed for severe pain rated 7 to 10. The March MAR documented that on one date the resident received oxycodone 5 mg at 7:47 a.m. for pain level 5 and then oxycodone 7.5 mg at 9:37 a.m. for pain level 4, which was before the 6‑hour interval had elapsed. Additional MAR review showed that the resident received oxycodone 7.5 mg on multiple dates for pain levels of 3, 4, and 6, which did not meet the order requirement that this dose be used only for severe pain rated 7 to 10. In interviews, staff confirmed that the 7.5 mg oxycodone was administered both before the 6‑hour interval and for pain levels outside the ordered severity range, and that these administrations were in error.
Resident Lacked Access to Phone and Working TV Remote
Penalty
Summary
Surveyors identified a deficiency in which a resident did not have access to a personal or facility-provided phone and had a non-functioning TV remote control in their room. During review of an intake alleging multiple concerns, staff confirmed that there was only one phone jack in the semi-private room, and that the single phone line was connected to the roommate’s phone. The resident therefore did not have a phone of their own in the room. When asked how the resident communicated privately with family, a GNA and an RN stated that the resident sometimes used the roommate’s phone, and the RN confirmed that the resident did not have a personal or facility phone. Further observation in the resident’s room with the Administrator and Maintenance Director showed that there was only one phone jack available in the room, consistent with prior staff statements. During the same observation, the surveyor asked whether the resident’s TV remote control worked. The Maintenance Director attempted multiple times to turn on the TV using the remote and was unable to do so, ultimately turning the TV on manually. These observations confirmed that the resident lacked direct access to a working phone and a functioning TV remote control in their room.
Call Lights Left Out of Residents’ Reach
Penalty
Summary
The facility failed to ensure that residents' call lights were within reach for 3 of 105 residents observed during the initial tour. During screening and observation rounds on the second unit hallway, Resident #60 was found in the room with the call light on the floor. Resident #107 and Resident #67 were observed in their room with both call lights out of reach; Resident #67's call light was on the floor, and Resident #107's call light was hanging from the top of the bed onto the floor. Both Resident #107 and Resident #67 complained of pain at the time of observation. A nurse entered the room, retrieved the call bells, and placed them within the residents' reach.
Restricted Visiting Hours Posted at Entrance
Penalty
Summary
The facility failed to ensure residents were permitted to receive visitors at any time in accordance with resident rights by imposing facility-wide visiting hours. During observation, a sign taped to the glass entrance door stated that visiting hours had ended Monday through Sunday from 8:00 AM to 8:00 PM and on holidays from 9:00 AM to 5:00 PM, indicating restricted visitation outside those times. The Administrator stated residents are allowed visitors at any time and was unaware of the origin of the posted sign. Multiple residents later confirmed that the posted visiting hours reflected the facility's current visitation practice. The Receptionist stated she places the sign on the door each evening at 8:00 PM when she leaves and removes it upon her return at 8:00 AM, and that the front entrance door is locked after 8:00 PM. She also stated visitors would need to use a side doorbell to gain entry outside the posted hours, but there was no signage informing visitors of the doorbell.
Grievance Process and Follow-Up Deficiencies
Penalty
Summary
The facility failed to honor residents’ rights to voice grievances anonymously and did not make blank grievance forms readily available in prominent locations. During a tour, surveyors observed that blank grievance forms were not posted in visible areas, and later found that forms were not available at the lobby front desk or at the nurse station counters, requiring staff to retrieve them from back areas on request. The Administrator stated that residents could submit grievances to the Administrator, DON, or Social Work staff, but the record review showed that the prior paper grievance system had Social Work staff initiating grievance forms rather than residents submitting them directly or anonymously. The review also found no record of grievance resolution statements being provided back to residents, and during Resident Council most residents reported they were unaware of the grievance process or where to access blank forms. The facility also failed to provide prompt follow-up responses to a resident’s grievance. Resident #55 reported during Resident Council that a staff member had been rough while transporting him/her in a wheelchair, and the Administrator confirmed that this concern was raised at the meeting. When asked whether follow-up had been completed, the Administrator stated that no follow-up was done and acknowledged forgetting to address the concern. The Administrator further confirmed that the resident later raised the same concern again in a separate conversation, and stated that the grievance process normally includes follow-up on concerns.
Unclear indication for antipsychotic medication
Penalty
Summary
The facility failed to ensure that psychotropic medication use was supported by a clear, appropriate, and documented clinical indication for Resident #21. The resident had a physician order dated 03/16/2026 for Seroquel (quetiapine) 75 mg by mouth at bedtime, given as one 50 mg tablet and one 25 mg tablet. The medical record listed the indication for use as "psychotic symptoms," which did not reflect a specific diagnosed condition and was not a clinically appropriate or sufficient indication to support antipsychotic use. During interview, the Psychiatric Nurse Practitioner stated that the indication for use had been entered incorrectly in the electronic medical record, and the resident's record was later updated to include a diagnosis intended to reflect an appropriate clinical indication.
Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure an alleged abuse/neglect incident was reported to the regulatory agency within 2 hours after staff became aware of it. Resident #117 was involved in an incident on 03/17/26 during a wound assessment when Wound Nurse Staff #38 allegedly hit the resident on the back. According to the Administrator, staff became aware of the incident at approximately 1:00 PM that day, but the initial report was not submitted to the Office of Health Care Quality until 3:16 PM. The record review and interviews showed that Resident #117 voiced pain and discomfort and asked Staff #38, "Why did you hit me?" The Administrator’s interview statement also noted that Staff #38 did not respond to the resident’s question and walked out of the room. The resident’s family confirmed they were present during the incident and heard the resident ask the staff why they were hit. The report states that the delay in notifying OHCQ exceeded the required 2-hour reporting window.
Failure to Provide Replacement Meal After Breakfast Was Not Consumed
Penalty
Summary
The facility failed to ensure that Resident #21 received the planned breakfast meal or an alternative meal or nutritional supplement after the original meal was not consumed. During a breakfast observation on 03/18/2026 at approximately 9:00 AM, the resident was seen propelling self in a wheelchair in the hallway while the meal tray remained on the bedside table in the room. The resident's plate was observed on the floor with oatmeal and eggs spilled, and the amount of food on the floor indicated the meal had not been eaten. The resident's record showed cognitive impairment and recent weight loss, placing the resident at increased risk for inadequate nutritional intake. The DON was made aware of the situation and notified housekeeping to clean the spilled food, but there was no evidence the resident was assessed for meal consumption or offered a replacement tray, substitute meal, or nutritional supplement. The CDM stated no additional breakfast tray had been requested, and Staff Nurse #15 stated she was not aware the resident required a replacement meal. There was no documented evidence that the resident received adequate nutrition after the meal was not consumed.
Pharmacist Failed to Report Irregular Antipsychotic Order
Penalty
Summary
The facility failed to ensure the consultant pharmacist identified and reported an irregularity during the monthly drug regimen review for one resident. Resident #21 had a physician order for Seroquel (quetiapine) 75 mg by mouth at bedtime, given as one 50 mg tablet and one 25 mg tablet. The documented indication for the antipsychotic was listed as "psychotic symptoms," which was nonspecific and did not reflect a diagnosed clinical condition or an appropriate indication for the medication, creating an irregularity in the order. During interview, the Psychiatric Nurse Practitioner stated the indication had been entered incorrectly in the electronic medical record, and the resident's record was later updated to include a diagnosis intended to support the medication's use. There was no evidence that the consultant pharmacist identified, documented, or reported the inaccurate and incomplete indication during the medication regimen review.
Duplicate Colace Orders Resulted in Unnecessary Medication Administration
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary medication when Resident #132 had duplicate orders for Colace (docusate sodium) in the medical record. On 12/18/2025, the physician ordered Colace 100 mg by mouth twice a day for constipation, and on 12/22/2025, the physician ordered Colace 100 mg by mouth every 12 hours for constipation. Review of the January 2026 MAR showed the resident received Colace multiple times in a manner consistent with duplicated administration, including once on day shift and twice on evening shift on 01/01, twice on day shift and twice on evening shift on 01/03, twice on day shift on 01/04, once on day shift and twice on evening shift on 01/05, twice on evening shift on 01/06, twice on day shift and twice on evening shift on 01/07, and twice on day shift on 01/08. During interview, staff #2 reviewed the MAR with the surveyor and agreed the Colace orders were duplicated and administered in error.
Unsafe Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to procure, store, prepare, distribute, and serve food under sanitary conditions and in accordance with professional standards for food safety. During an annual survey kitchen observation on 3/18/26, surveyors observed seven pre-poured syrup containers stored on a visibly soiled utility table without labels or dates, an open and unlabeled container of salad dressing in the walk-in refrigerator, opened bread products without labeling or dating, and multiple unlabeled items in the dry storage room. Food debris and a liquid substance were also observed on the kitchen floor near the walk-in freezer, and a red substance was spilled across metal shelving in the walk-in refrigerator. Additional observations showed the walk-in freezer had a buildup of ice beneath storage racks where food was maintained, and the three-compartment sink contained large pots while the Chemical Sanitation log showed the last documented entry was 3/17/26. During interview, the Certified Dietary Manager acknowledged the findings and confirmed the practices were not in accordance with facility policy or accepted food safety standards.
Infection Control Lapses in Linen Storage and Laundry Areas
Penalty
Summary
The facility failed to maintain proper infection control practices by storing soiled linen in the same room as clean linen. During environmental rounds, a room labeled bath was observed to contain three large trash cans filled with soiled linen, while two carts containing clean linen were also stored in the same room. Housekeeping Staff #42 stated that soiled linen should not be stored in the same room as clean linen, and GNA Staff #43 stated they were unsure how the clean linen carts were placed in the room but would remove them. The facility also failed to maintain an infection prevention and control practice to provide a safe and sanitary laundry service area. Staff personal items were observed on folding tables in the dryer room, personal lockers in the washer area were not being utilized, and staff personal belongings, including food and drinks, were found in two areas of the laundry service. Laundry Supervisor Staff #6 agreed with these concerns and stated staff would be redirected immediately. These findings were shared with the ADON/Infection Control Staff #8 and the Administrator as a deficiency practice concern.
Pest Control Failure With Ants in Resident Rooms
Penalty
Summary
The facility failed to maintain a sanitary, pest-free environment after ants were observed in resident rooms on the 1st floor during survey rounds. Residents reported that ants had already been brought to maintenance, but the concern remained unresolved when the surveyor observed several residents describing ants in their rooms. Nursing staff stated that the facility uses a TELS electronic maintenance request system to enter concerns and generate work orders for maintenance, but no evidence was provided that the pest concerns had been addressed in a timely manner. On follow-up observations, ants were still present in multiple resident rooms, and one resident was observed with several ants crawling on a bag sitting on the nightstand while the resident stated that ants were moving along the window sill looking for food. The Administrator was informed of the concern later in the survey process.
Missing Annual Abuse, Neglect, and Exploitation Training for PRN and Part-Time GNAs
Penalty
Summary
The facility failed to provide evidence that part-time and PRN geriatric nursing assistants (GNAs) received annual education on abuse prevention, neglect, and exploitation. During the annual survey, 7 of 8 GNA employee and education files reviewed for staff #17, #21, #22, #24, #30, #39, and #40 did not show the required annual training. The surveyor interviewed the ADON/staff educator and the HR director, who stated that part-time and PRN GNAs were not required to demonstrate compliance with the facility’s annual clinical training requirements, and that the annual hands-on competency training was usually offered between January and March, with the 2026 competencies not yet offered at the time of the interview. The review of human resource files and the list of PRN and part-time GNA staff on 03/26/2026 showed that the DON and administrator failed to ensure annual abuse, neglect, and exploitation clinical training was completed for these staff members. The ADON stated that she and the HR director used a spreadsheet to track competency due dates, but the survey findings showed no evidence that the required annual training had been completed for the affected part-time and PRN GNAs.
Failure to Ensure Annual Clinical Training for PRN and Part-Time GNAs
Penalty
Summary
The facility failed to have a system in place to ensure that PRN and part-time geriatric nursing assistants (GNAs) received at least 12 hours of annual clinical in-service training. During an interview, the ADON and staff educator stated that the facility used a spreadsheet to track annual competency due dates for full-time GNA staff, and also stated that part-time and PRN GNA staff were not required to meet the annual clinical competency and/or annual Relias online clinical training requirements. The DON and ADON later agreed that the facility was not requiring PT and PRN GNA staff to complete the same annual mandatory clinical education hours as full-time staff. Review of employee human resource records, education training records, spreadsheets, and interviews showed that 7 of 8 part-time or PRN GNA files reviewed did not contain evidence of the required 12-hour annual clinical training. The administrator provided policies on abuse, neglect, exploitation, HR-024 Orientation, and Continuing Education, but the facility did not provide a policy that included an exemption of PRN and part-time GNA staff from mandatory annual clinical in-service training.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to complete and transmit the Minimum Data Set (MDS) assessments for 27 out of 33 residents reviewed during the annual survey. The MDS is a critical component for assessing the needs of residents in nursing homes, and timely submission is required to ensure proper care. The assessments were not completed and transmitted within the required 14-day period following the Assessment Reference Date (ARD) for various types of assessments, including annual, quarterly, and discharge assessments. The Lead MDS Coordinator acknowledged the delay in completing the assessments, attributing it to an increased number of facility admissions and a reduction in the number of nurses responsible for completing the MDS assessments from three to two. The facility prioritized Medicare assessments over Medicaid and private ones, which contributed to the delay. The Nursing Home Administrator and the Director of Nursing were informed of the issue, highlighting the facility's awareness of the deficiency.
Facility Fails to Maintain Safe Hot Water Temperatures
Penalty
Summary
The facility failed to ensure a safe environment by not maintaining acceptable hot water temperatures in resident bathroom sinks. During a recertification survey, surveyors observed that the hot water temperatures in several resident rooms exceeded the maximum allowable limit of 120 degrees Fahrenheit, with temperatures recorded as high as 128.2 degrees Fahrenheit. The Maintenance Director (MD) stated that weekly water temperature monitoring was conducted and documented in TELS, but no recent concerns had been noted. Despite the mixing valve being set at 118 degrees Fahrenheit, the observed temperatures were significantly higher. The MD was unable to explain the discrepancy between the mixing valve setting and the actual water temperatures. An observation of the water system showed the mixing valve temperature at 114 degrees Fahrenheit, yet the water temperatures in resident rooms remained elevated. The MD suggested that the temperature variations could be due to the continued use of water, but no definitive explanation was provided. This deficiency has the potential to affect all residents in the facility.
Failure to Ensure Homelike Environment and Accommodate Resident Needs
Penalty
Summary
The facility failed to provide a homelike environment and accommodate the needs of residents, as observed during a survey. Multiple environmental concerns were noted in resident rooms, including stained ceiling tiles, missing bathroom call bell pull cords, holes in walls, and a plastic bag covering a smoke detector. These issues were acknowledged by the Nursing Home Administrator during a tour of the facility. The lack of a homelike environment was evident for several residents, as these deficiencies were observed in multiple rooms. Additionally, a resident expressed discomfort due to an air mattress that was not ordered by a physician and caused difficulty sleeping. Despite informing the nursing staff about the discomfort, the issue was not addressed promptly, taking three days to resolve. The resident's discomfort and inability to sleep were communicated to the Unit Manager and the Assistant Director of Nursing, highlighting a failure to accommodate the resident's needs in a timely manner.
Failure to Complete MDS Assessments Timely Due to Staffing Issues
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required timeframe for six residents during the annual survey. The MDS assessments, which are crucial for ensuring residents receive appropriate care, were not completed within the 14-day period following the Assessment Reference Date (ARD) as mandated by CMS guidelines. Specifically, the assessments for five residents were more than 30 days overdue, and the initial comprehensive assessment for another resident was not completed within 14 days of admission. The Lead MDS Coordinator acknowledged the delay in completing the assessments, attributing it to an increased number of facility admissions and a reduction in the number of nurses responsible for MDS assessments from three to two. The Nursing Home Administrator and the Director of Nursing were informed of these findings, which highlight the facility's inability to adhere to the required timelines for MDS assessments due to staffing issues.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (MDS) assessments within the required timeframe for 18 out of 33 residents reviewed during the annual survey. The MDS is a core set of data elements that form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. According to CMS guidelines, an MDS Quarterly assessment must be completed within 14 days of the Assessment Reference Date (ARD). However, the review revealed that the assessments for the identified residents were still in progress and not completed within the specified timeframe. The Lead MDS Coordinator confirmed the delay in completing the assessments, attributing it to an increased number of facility admissions and a reduction in the number of nurses available to complete the MDS assessments, from three to two. Currently, only the Lead MDS Coordinator and an LPN are responsible for completing these assessments. The Nursing Home Administrator and the Director of Nursing were notified of this concern.
Deficiencies in Care Plan Meetings and Documentation
Penalty
Summary
The facility failed to provide invitations to residents for care plan meetings, did not conduct care plan meetings as required, and did not revise care plans for several residents. This deficiency was identified in five out of ten residents reviewed. For instance, Resident #1, who had moderate cognitive impairment, was not invited to care plan meetings, and there were no conference notes or invitations documented. The social worker responsible could not explain the lack of invitations, and the administrator acknowledged the deficient practice. Resident #62 reported not recalling recent care plan meetings, and the medical record review showed only one documented meeting in the past year. The Nursing Home Administrator confirmed the lack of additional documentation for care plan meetings for this resident. Similarly, Resident #58 stated they had never been invited to a care plan meeting, and the records showed only two documented meetings in the past year, with no invitation for the August 2024 meeting. Additionally, there was a discrepancy in Resident #58's care plan regarding dialysis access, which was not updated to reflect the current AV Fistula. Residents #158 and #164 also experienced deficiencies in care plan meetings. Resident #158 had only one documented care plan meeting since May 2022, and Resident #164 had only one documented meeting during their stay from December 2022 to January 2024. The social service designee confirmed that care plan meetings were not up to date, and the Nursing Home Administrator acknowledged the lack of documentation and the late status of care plan meetings for these residents.
Deficiencies in Medical Record Accuracy and Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for several residents, as evidenced by discrepancies in documentation and missing records. For instance, Resident #94's activity participation was not accurately documented in the electronic health record (PCC) for December 2024 and January 2025, and there was no evidence to support the resident's attendance in activities according to their care plan. Similarly, Resident #256's activity participation was not documented in PCC, and there was no evidence of the resident's newspaper reading activities or refusals to attend activities. Additionally, the facility did not ensure the accuracy of medication administration records. Resident #166 did not receive Atorvastatin Calcium for ten days, as confirmed by a review of the Medication Administration Record (MAR) and an interview with the Assistant Director of Nursing. Furthermore, Resident #455 was observed lying on a standard mattress instead of the ordered air mattress, despite the Task Administration Record (TAR) indicating that the air mattress was monitored and functioning correctly. The facility also failed to maintain accurate Medical Orders for Life-Sustaining Treatment (MOLST) forms. Resident #1, who had moderate cognitive impairment, was incorrectly marked as a cognitive intact consent party on the MOLST form. Similarly, Resident #10, with a history of cognitive impairment, had a MOLST order form that did not accurately reflect their cognitive status. These deficiencies highlight the facility's failure to ensure accurate documentation and adherence to professional standards in maintaining medical records and orders.
Neglect of Resident's ADL Care Leads to Distress
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, as evidenced by the case of a resident who did not receive necessary Activities of Daily Living (ADL) care during an entire shift. The resident was found with a soaked gown and bed linen, which caused significant distress. The complaint, submitted to the Office of Health Care Quality, highlighted that the resident's call light was on, and the resident expressed a need to be cleaned and have their wet bed linens changed. The night shift staff discovered the resident in this condition, indicating that the neglect occurred during the evening shift. A health status note from an LPN documented that the resident's diaper and bed had been wet throughout the evening shift, leading to bed soreness. The resident was in distress and screaming due to the lack of care. The LPN and an aide eventually attended to the resident's needs. During an interview, the Director of Nursing acknowledged awareness of the incident and mentioned providing in-service training to the LPN involved for proper documentation and reporting of patient concerns.
Failure to Obtain Statement from Alleged Perpetrator in Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident. A family member reported that the resident's Geriatric Nurse Assistant (GNA) allegedly hit the resident in the back of the head five times. The incident was reported approximately two weeks after it allegedly occurred. The resident, who had a BIMS score indicating moderate cognitive impairment, denied being hit when interviewed. Other staff and residents also denied knowledge or witnessing any abuse. Despite these interviews, the facility did not obtain a statement from the alleged perpetrator, which was a critical step missing in the investigation process. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were involved in the investigation. They followed several protocols, such as removing the alleged staff from the schedule, conducting a head-to-toe assessment of the resident, notifying the doctor and family, involving the Social Worker, and reporting the incident to law enforcement. However, the failure to obtain a statement from the alleged perpetrator was a significant oversight in the investigation, as acknowledged by the NHA when made aware of the deficiency.
Failure to Ensure Resident Dignity and Staff Identification
Penalty
Summary
The facility failed to ensure the dignity of its residents, as evidenced by two specific incidents involving nursing staff. In the first incident, a Geriatric Nursing Assistant (GNA) entered a resident's room without knocking, which was confirmed during an interview with the resident and the GNA. The GNA acknowledged the expectation to knock before entering and admitted to not doing so. In the second incident, another GNA was observed without a visible name badge while delivering food outside a resident's room. Upon inquiry, the GNA confirmed that all staff were expected to wear name tags, and she was later seen with a makeshift name tag made from tape. These actions were reported to the Nursing Home Administrator and the Director of Nursing at the time of the surveyor's exit.
Inaccurate MDS Discharge Coding
Penalty
Summary
The facility failed to accurately code a resident's discharge status on the Minimum Data Set (MDS) assessment. This deficiency was identified for one resident who was reviewed for hospitalizations during the survey. The resident was discharged to another nursing home, as indicated in the discharge summary dated October 8, 2024. However, the MDS Discharge Return Not Anticipated assessment incorrectly recorded the discharge status as a short-term general hospital (acute hospital). This discrepancy was confirmed through interviews with the Social Worker Director, a Licensed Practical Nurse, and the Lead MDS Coordinator, who acknowledged the error and indicated that the assessment should reflect the discharge to another facility. The Nursing Home Administrator was informed of the MDS inaccuracy.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their specific health needs. Resident #355 experienced constipation from late December 2024, but no bowel regimen was initiated until January 2025. Despite receiving various medications for constipation starting January 2, 2025, there was no evidence of a care plan to address this issue. The resident reported that the medication led to diarrhea and vomiting, indicating a lack of effective management and planning for the resident's condition. Resident #356, diagnosed with irritable bowel syndrome (IBS), experienced non-stop diarrhea and was seen by a Nurse Practitioner on January 8, 2025, for nausea, vomiting, and diarrhea. The NP ordered IV hydration and other treatments, but there was no care plan developed for the use of IV fluids for hydration. The Unit Manager and Assistant Director of Nursing confirmed the absence of a care plan for this resident's hydration needs, highlighting a gap in the facility's care planning process. Resident #12, who was dependent on staff for activities of daily living (ADLs) due to conditions such as schizophrenia, muscle weakness, and intellectual disabilities, did not have a care plan addressing their dependence on staff for personal hygiene, bathing, dressing, and toileting. Despite being aware of the resident's needs, the staff failed to initiate and implement a care plan to ensure adequate support for ADLs. This oversight was acknowledged by the Director of Nursing, who was informed of the findings.
Failure to Provide Individualized Activities Program
Penalty
Summary
The facility staff failed to provide an ongoing activities program tailored to meet the needs and preferences of a resident, identified as Resident #94. Observations made during the survey revealed that the resident was frequently found sitting in a wheelchair in the hallway across from the nurses' station, not participating in any activities. The resident's Minimum Data Set (MDS) assessment indicated a strong preference for activities such as reading, listening to music, keeping up with the news, participating in group activities, and engaging in religious services. Despite these documented preferences, the resident's activity care plan, which required participation in activities of choice 3-5 times weekly, was not effectively implemented. Interviews with facility staff, including the Assistant Director of Nursing and the Activities Director, confirmed that while the resident was sometimes taken to group activities, they often did not stay long due to yelling out. The Activities Director acknowledged familiarity with the resident's preferences and health conditions but admitted to having limited documentation of the resident's participation in activities. A review of the resident's activity participation records showed minimal engagement, with only two days of documented activities in November 2024 and no records for December 2024 and January 2025. This lack of documentation and observed inactivity indicates a failure to provide a personalized and consistent activities program for the resident.
Failure to Schedule Neurology Consultation for Resident
Penalty
Summary
The facility failed to follow up on a recommendation for a neurology consultation for a resident who was readmitted with a primary diagnosis of New Onset Seizure. The resident's discharge summary from the hospital requested an appointment with a Neurologist within four weeks of discharge. Despite multiple progress notes from physicians and nurse practitioners indicating the need for a follow-up with neurology, there was no documentation in the resident's clinical record to confirm that an appointment was scheduled or attended. Interviews with facility staff revealed a lack of clarity and follow-through in the process of scheduling the necessary consultation. Staff members, including the Nurse Manager, Nurse Supervisor, or Charge Nurse, were responsible for making appointments based on physician orders and hospital recommendations. However, they were unable to confirm whether the neurology appointment was scheduled. The Medical Director acknowledged the oversight and noted that the resident was stable on medication, suggesting that a consultation was not deemed necessary after two months.
Failure to Follow Respiratory Care Protocols
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident, as observed during a survey. The surveyor noted that the oxygen humidifier bottle and tubing attached to the oxygen concentrator in the resident's room were not dated, and there was no oxygen usage sign on the resident's room door or doorframe. The resident had physician orders for oxygen therapy and a care plan related to respiratory illness, which included changing the oxygen tubing and humidifier bottle weekly on the night shift. The facility's policy required an oxygen sign on the resident's door and specified that the tubing and humidifier bottle should be changed weekly and every seventy-two hours, respectively. During an interview, the Director of Nursing acknowledged that the expected procedures for oxygen signage and equipment changes were not followed for this resident, indicating an oversight in adhering to the facility's policy.
Failure to Timely Discontinue Medication as Ordered
Penalty
Summary
The facility failed to discontinue a medication in a timely manner as ordered by the attending physician for a resident with diagnoses including Cognitive Communication Deficit, Major Depressive Disorder, and Psychosis. The resident was admitted to the facility, and on September 11, 2024, the Licensed Pharmacist recommended discontinuing Oxycodone PRN as it was not utilized by the resident. The physician reviewed this recommendation and ordered the discontinuation of the medication on September 17, 2024. However, the facility did not follow up on this order, and the medication was not discontinued until November 15, 2024, after a second recommendation from the pharmacist on November 12, 2024. The Director of Nursing confirmed the findings during an interview, explaining the process for handling pharmacy recommendations and the failure to implement the physician's order.
Failure to Provide Prompt Dental Care
Penalty
Summary
The facility staff failed to promptly provide or obtain dental services for a resident, leading to a deficiency. During a floor rounding, the resident reported a dental issue involving a cap that had fallen out, causing pain. The resident had informed the staff about this issue upon admission. A review of the resident's records revealed that an initial dental assessment was conducted by a social worker, identifying a broken or loose-fitting tooth. However, the assessment was later altered to indicate no dental issues, and the resident was not referred to the on-site dental service. The resident was admitted with severe protein-calorie malnutrition and encephalopathy, which could have been exacerbated by the dental issue. Despite the initial identification of a dental problem, the facility did not ensure the resident received the necessary dental care. The administrator acknowledged the failure to provide or schedule a dental visit, confirming the deficiency in the facility's response to the resident's dental needs.
Deficiencies in Meal Service and Dietary Adherence
Penalty
Summary
The facility failed to provide meals that adhered to the dietary preferences and needs of three residents, leading to deficiencies in food service. Resident #455 received breakfast trays that did not match the meal tickets, missing items such as biscuits, gravy, coffee, and milk. The resident expressed concerns about inadequate food supplies, as syrup was provided instead of butter and jelly. The Nursing Home Administrator confirmed that the kitchen did not prepare the menu items as indicated, such as French toast. Resident #255, who follows a gluten-free diet, repeatedly received meals that did not align with this dietary restriction. The resident's meal tray included items like muffins and sausage patties that were not suitable for a gluten-free diet. The Dietary Manager acknowledged the oversight and attributed it to being understaffed, which delayed the updating of the resident's dietary preferences. Resident #357 experienced issues with receiving incorrect meal trays, resulting in missed meals. The resident reported that the staff removed incorrect trays but did not replace them, leading to missed breakfasts. The Registered Dietitian and Certified Dietary Manager were aware of the resident's specific preferences, but these were not documented in the electronic charting system, contributing to the discrepancies in meal service.
Failure to Meet Dietary Needs and Provide Meals for Dialysis
Penalty
Summary
The facility failed to ensure that a resident's dietary needs were met and did not provide a lunch meal for a resident attending outpatient dialysis. For Resident #169, the facility did not adhere to the prescribed low-fat, low-residue diet as required by the resident's medical condition. The hospital discharge summary indicated a need for a low fiber, low insoluble residue diet, avoiding coffee and dairy. However, the resident was placed on a regular diet with mechanical soft texture upon admission. The Registered Dietician and Dietary Manager were unable to verify the initial diet order sent to the kitchen due to the absence of a copy of the diet card. The Dietary Manager noted that the resident's family had expressed dissatisfaction with the diet provided and had requested a low-fat diet, but there was no documentation of when these changes were made. For Resident #58, the facility did not provide a lunch meal to accompany the resident on scheduled dialysis days, despite the resident leaving the facility after breakfast and returning around 4:00 PM. The resident reported not receiving lunch at the dialysis center, and the meal tray was observed left on the food delivery cart. The assigned RN confirmed that the facility did not provide a lunch for the resident on dialysis days. The Nursing Home Administrator and Director of Nursing were informed of the issue, but no additional information was provided regarding the provision of lunch for the resident.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,156 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bethesda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maplewood Park Place | 1 mi | ★★★★★ | 0 | 0 |
| Sterling Care Bethesda | 1.3 mi | ★★★★★ | 24 | 0 |
| Tuckerman Rehabilitation And Healthcare Center | 1.8 mi | ★★★★★ | 5 | 0 |
| Montcare At Bethesda | 2 mi | ★★★★★ | 14 | 0 |
| Autumn Lake Healthcare At Chevy Chase | 2 mi | ★★★★★ | 5 | 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 July 2026) and official state health department websites.