Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Sterling Care Bethesda during CMS and state inspections, most recent first.
A resident with quadriplegia and multiple contractures was left without a functional customized motorized wheelchair for an extended period after the device broke and repair invoices were not paid, leaving the wheelchair inoperable. The resident reported being unable to move around the facility for several months, and the Director of Rehab confirmed the wheelchair had been broken since the previous year. The DON stated the wheelchair was not repaired because the resident could no longer safely operate it, but clinical records showed the resident was not assessed and deemed incapable of using a motorized wheelchair until months after the wheelchair became inoperable, and there was no documentation that a substitute motorized wheelchair was provided during this time.
The facility failed to notify a resident's legal guardian of changes in condition for one resident who was unable to make medical decisions and had a guardian involved in care planning. Documentation showed three change-of-condition events, but only one included evidence that the guardian was notified. The DON confirmed the guardian should have been called and updated, and no explanation was provided for the missed notifications.
Unsafe Lighting, Poor Housekeeping, and Damaged Driveway Conditions: Surveyors observed flickering lights on two units, dirty and poorly maintained resident areas including a soiled bathroom and stained room floor, and an uncovered food item left in a resident room. They also found multiple potholes along the facility driveway used by a resident in a motorized wheelchair, with the Administrator aware of the issue but delaying repairs.
Missing physician documentation for hospital transfer and discharge. Two residents were transferred to the ED and later discharged, but the records lacked physician notes explaining the reason for transfer and, for both residents, lacked discharge documentation summarizing the clinical course or basis for discharge. One resident’s chart also did not document the resident’s whereabouts when the resident was off the unit, and staff later confirmed the resident had been admitted to the hospital due to a change in mental status.
Failure to Provide Written Bed Hold Notice: A resident was transferred to the ED, and while the RP was notified and understood the bed hold policy, the record did not show that a written bed hold notice was provided. The ADON stated that a bed hold notice and transfer notice are completed at transfer and sent to the RP if not present, but the facility could not produce documentation confirming the written notice was given.
Inaccurate MDS coding was found for two residents. One resident’s MDS did not document a fall with major injury in the falls section, and another resident’s MDS incorrectly showed insulin injections even though no insulin order was present. The MDS coordinators confirmed the errors during survey review.
A resident admitted with metabolic encephalopathy and cognitive communication deficient did not have evidence in the record that the RP received a written summary of the baseline care plan. The SW stated baseline care plans are completed with the RP for residents without cognitive capacity, but the chart lacked documentation of the meeting and lacked proof that the written summary was provided.
Inaccurate Hospice Care Plan: A resident receiving hospice services had a joint hospice/facility care plan that listed shared responsibilities for symptom control, skin integrity, hygiene, feeding, and psychosocial and spiritual support, but interviews showed the documented bathing and feeding services were not actually provided as written. The hospice nurse stated the resident did not receive GNA bathing or feeding services, and the SSA was unsure about other hospice support staff.
Failure to hold and document care plan meetings: The facility did not hold interdisciplinary care plan meetings for a resident at the time of quarterly and annual MDS review and did not invite the resident or RP to the meetings. The record showed no evidence of meetings within the required timeframe, and the SWD later confirmed the findings after reviewing the chart.
A resident who required ADL assistance did not receive a scheduled shower, and the missed shower was confirmed by the resident’s report and by review of the EMR and shower book. The UM stated staff were required to document showers in both records and acknowledged the resident likely did not receive the shower as scheduled.
Failure to provide consistent splinting for a resident with a hand contracture. The resident had a left resting hand splint recommended by OT for 8 hours per day, but the splint was often not on the resident, the resident said help was sometimes needed and no one had offered to put it on, and there was no order or TAR for the splint. The functional maintenance log also showed multiple blank weekends over several months, despite the resident being on the daily schedule.
A resident’s IV antibiotic therapy had been discontinued, but the IV line remained in the left upper arm with bloody fluid visible in the tubing and on the dressing. An RN stated the IV should have been removed when the antibiotics were finished and confirmed the dressing had been in place longer than the 7-day change interval.
Incomplete and inaccurate records were found for multiple residents. A resident’s chart was missing urology consult notes and ultrasound results after a UTI-related hospitalization, another resident’s hospice record had gaps and did not reflect weekly hospice visits, and two residents’ EHR entries incorrectly showed enhanced barrier precautions as not completed when staff confirmed they should have been marked yes.
Unsafe handling of soiled linen was observed in the Rosemary unit when a linen cart in the soiled utility room had its lid off and unbagged linen overflowing onto the floor. An LPN stated the clothes should be bagged and thought the linen was picked up once a week, and the DON acknowledged the concern regarding the unbagged, soiled linen.
The facility failed to serve meals at posted mealtimes and in line with resident preferences, resulting in multiple cognitively intact residents waiting 40–45 minutes or more for lunch, with some leaving the dining room without being served and others reporting that food was often cold, especially on weekends. One resident with diabetes, pancreatitis, lung and kidney disorders, and mineral metabolism issues reported chronic delays in receiving lunch, another with a fracture, central cord syndrome sequela, and anxiety disorder described routinely late and cold meals and staff irritation when asked to reheat food, and a third resident council president with anxiety, depression, and hypo-osmolality reported six months of late, sometimes cold meals and negative staff demeanor when reheating was requested. Staff interviews cited dietary staffing shortages and logistics problems as reasons for late meal delivery, despite observations that sufficient nursing and non-nursing staff were available to assist.
Surveyors found that several residents, many with dementia, diabetes, CKD, incontinence, and dependence on staff for ADLs, were using bathrooms with toilets that had large rust stains, black mildew-like buildup around the base, missing caulk, instability, and active water leakage. A cognitively intact resident reported that the toilet had been stained and leaking for some time despite daily housekeeping, and another ambulatory resident using a walker reported a leaking toilet and concern about slipping. Housekeeping staff stated they clean bathrooms daily and report problems but admitted leaving stains they could not remove and not reporting them, while the EVS manager acknowledged only partial daily room checks. The maintenance supervisor reported noticing rust and caulking issues weeks earlier, directing housekeeping and a technician to address them but not following up, resulting in ongoing unsanitary and nonfunctional toilet conditions contrary to facility policies for a safe, clean, and homelike environment.
A resident with Alzheimer's and schizophrenia was physically abused by a geriatric nursing assistant, who was observed hitting the resident with a bag. The incident was substantiated by the facility's investigation, and the resident showed no signs of trauma. The nursing assistant was suspended and reported to the Maryland Board of Nursing.
Two residents were not provided adequate privacy, as one had an uncovered Foley catheter drainage bag visible from the hallway, and another had lower extremity dressings exposed to view by others. These lapses resulted in a failure to maintain resident dignity and privacy during care.
Surveyors found that several residents did not have advance directives documented in their medical records, and there was no evidence that they or their representatives had been given the opportunity to complete one. The Director of Social Services confirmed the absence of both the directives and related documentation.
Surveyors found that the facility failed to provide a clean, safe, and homelike environment, with issues such as marred walls, dirty floors, inaccessible trash cans, loose bathroom fixtures, broken toilet paper holders, stained ceiling tiles, and the presence of substances with strong odors in resident rooms and bathrooms. These deficiencies were observed in multiple resident areas and were reported to facility leadership.
Nursing staff did not follow professional standards by inaccurately documenting medication administration for two residents. One resident refused a prescribed medication, but it was recorded as given, while another did not receive several medications, including Zinc, which was marked as administered despite being unavailable. The MAR lacked proper documentation of medication unavailability, and the nurse confirmed signing off on medications that were not given.
A resident who had resumed a regular diet and was no longer using a PEG tube for nutrition repeatedly requested tube removal, but the facility failed to timely schedule the recommended MBSS to assess swallowing safety. Despite documentation of the resident's improved condition and notification to the DON and administrator, the assessment and removal process was delayed.
Staff failed to maintain a medication error rate below 5%, with an LPN administering an incorrect insulin dose until corrected, documenting medications as given when they were refused or unavailable, and recording administration of several medications that were not actually provided to two residents.
A nurse prepared and nearly administered 30 units of insulin to a resident with diabetes, instead of the ordered 24 units, before being corrected by a surveyor. The nurse, with one year of experience, adjusted the dose after intervention, and the resident's MAR confirmed the correct order.
Surveyors found expired intravenous drugs, a COVID self-test kit, and an insulin injection pen in a medication storage room, indicating that staff had not discarded these items as required. An LPN was present during the observation, and the ADON confirmed that expired medications should have been removed.
A resident with lactose intolerance was repeatedly not provided with lactose-free milk as ordered, instead receiving regular milk or no milk at all. The resident reported this issue occurred often, and review of the menu sheet confirmed the correct order was not followed. Staff were made aware of the error, and the Dietary Manager later acknowledged the problem.
A strong, persistent ammonia urine-like odor was observed throughout the hallways and rooms of one unit. Staff and administration acknowledged the odor, but it remained present during multiple surveyor observations, resulting in an unsanitary and uncomfortable environment.
Failure to Maintain or Replace Resident’s Motorized Wheelchair
Penalty
Summary
The facility failed to reasonably accommodate a dependent resident's needs by not ensuring the resident's customized motorized wheelchair was in working condition or providing a substitute. The resident, who has quadriplegia and contractures of the lower legs, left elbow, and wrist, was admitted in 2014 and reported in an interview that their motorized wheelchair had been broken for several months, leaving them unable to move around in the facility. The Director of Rehab confirmed that the wheelchair had been broken since the previous year and that a vendor had submitted invoices totaling $441.34 for repairs on 09/26/25, but the facility did not pay these invoices, resulting in the wheelchair remaining inoperable. The DON stated that the wheelchair was not repaired because the resident's condition had declined and the resident was no longer capable of operating a motorized wheelchair. However, a review of the clinical record showed that Rehab assessed the resident on 4/13/26 and determined on that date that the resident was incapable of using a motorized wheelchair, with no documentation indicating incapacity prior to that assessment. The Director of Rehab confirmed these findings in the clinical record. The surveyor also noted that the wheelchair had been broken since 09/26/25 and that the clinical record lacked documentation that a substitute motorized wheelchair was provided during the period when the resident's wheelchair was inoperable.
Failure to Notify Legal Guardian of Resident Condition Changes
Penalty
Summary
The facility failed to ensure that the resident's responsible party and/or legal guardian was notified of changes in condition for Resident #6. Record review showed that Resident #6 was unable to make medical decisions and had a legal guardian established in 2004, and a phone interview confirmed the guardian was involved in care planning. Review of change-of-condition documentation showed three changes in condition dated 8/20/25, 11/6/25, and 12/15/25, but only the 8/20/25 event documented that the guardian was notified. During interview, the DON confirmed that the legal guardian should have been called and updated regarding the resident's change in condition. No additional information was provided to explain why the guardian was not notified for the 11/6/25 and 12/15/25 changes in condition.
Unsafe Lighting, Poor Housekeeping, and Damaged Driveway Conditions
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment on the Chesapeake and Gateway units, as well as in resident rooms and the driveway. On the Chesapeake unit, surveyors observed a flickering hallway light near the conference room and another flickering light in a common room at the end of the hall. The floor on the unit was in poor condition, with debris and trash scattered about and sticky residue present in multiple areas. In one resident bathroom, the trash can was full, toilet tissue was on the floor, the toilet had a brown substance smeared around the seat, and the sink had black and brown stains. In another resident room, an uncovered food item was left on the windowsill and yellow stains were observed on the floor by bed B. A resident stated the rooms were not kept clean. On the Gateway unit, a flickering light above the nursing station made the hallway appear dim. In addition, several potholes were observed along the facility driveway leading to the main road. A resident who used a motorized wheelchair independently reported using the driveway to leave the facility and participate in community activities, and the Ombudsman had previously emailed the Administrator about the potholes. Surveyors observed residents struggling to navigate the driveway, and the Administrator acknowledged the complaints and stated he had obtained repair invoices but was waiting until after winter to proceed. The driveway remained unrepaired until staff filled the potholes after the surveyor intervened.
Missing physician documentation for hospital transfer and discharge
Penalty
Summary
The facility failed to document the reason for hospital transfer and discharge for two residents reviewed for inappropriate discharge. For one resident, the medical record showed admission to the facility in January 2026 and transfer to the emergency department on 02/20/2026, but there was no physician note documenting the reason for the transfer. The record also showed discharge from the facility on 02/21/2026, yet it lacked physician documentation summarizing the resident’s clinical course and care provided. During interviews, the DON stated that for residents transferred to the hospital and not returning, the physician did not complete a transfer note or discharge note. For the second resident, the surveyor observed the resident was not in the room during the initial unit tour, and the medical record did not document the resident’s whereabouts. Staff later stated the resident had been transferred to the hospital earlier that morning, and a progress note documented transfer to the emergency department. A follow-up note stated the hospital reported the resident had been admitted due to a change in mental status. The resident was later discharged from the facility on the same day, but the record lacked physician documentation supporting the basis for discharge, and the DON was unable to provide a physician discharge summary at exit.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide Resident #195’s responsible party with a written bed hold notice after the resident was transferred to the emergency department. Record review showed the resident was sent to the ED on 02/20/2026, and although the responsible party was notified of the transfer and verbalized understanding of the bed hold policy, the record did not contain evidence that a written copy of the bed hold notice was provided. During interview, the ADON stated that when a resident is transferred to the hospital, the assigned nurse completes a bed hold notice and transfer notice, and if the responsible party is not present, a copy is sent to them; however, the surveyor requested documentation to confirm that the written notice had been provided and the facility was unable to produce it. The DON was informed of the concern and acknowledged it.
Inaccurate MDS Coding for Falls and Medications
Penalty
Summary
The facility failed to accurately document Minimum Data Set (MDS) assessments for 2 of 51 residents reviewed. For one resident, the MDS assessment did not include a fall with major injury in section J1900, Number of Falls Since Admission/Reentry, even though the surveyor found no documentation of that event in the assessment record. For another resident, the MDS assessment in section N, Medications, documented 7 days of insulin injections during the reviewed time frame, but the resident’s orders showed no insulin ordered during that period. During interview, the MDS coordinator confirmed the first omission, and the MDS coordinator for the second resident confirmed the assessment was coded incorrectly.
Failure to Provide Written Baseline Care Plan Summary to RP
Penalty
Summary
Facility staff failed to ensure that Resident #123’s responsible party received a written summary of the resident’s baseline care plan within 48 hours of admission. Resident #123 was admitted with multiple diagnoses including metabolic encephalopathy and cognitive communication deficient, and the resident’s family member was identified as the responsible party. Review of the medical record did not show evidence that the facility provided the responsible party with a written summary of the baseline care plan. During interview, the Social Worker stated that for residents who lack cognitive capacity, baseline care plans are conducted with the resident’s responsible party and documented in the record, but the surveyor found no documentation in either the electronic or paper record showing that the baseline care plan meeting occurred with the responsible party or that a written summary was provided. The Social Worker later acknowledged that a progress note documenting the meeting was not completed and that evidence of the written summary was not maintained.
Inaccurate Hospice Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to meet the needs of a resident receiving hospice services. The resident had a hospice order dated 10/28/25, and the facility care plan stated that hospice would provide visits to assist with care needs while the facility would work cooperatively with the hospice team to meet the resident’s spiritual, emotional, intellectual, physical, and social needs. A joint hospice and facility care plan dated 10/24/25 also identified shared responsibilities for symptom control, medication regimen, skin integrity, bladder/bowel function, personal hygiene, feeding, disease progression, psychosocial support, and spiritual care. During record review and interviews, the surveyor found that the documented care plan did not match the services actually provided. The joint care plan stated that hospice would provide bathing 2 times per week and feeding 2 times per week, with the facility providing these services 5 times per week, but the hospice nurse stated the resident did not receive GNA services for bathing and feeding. The Social Service Assistant stated he saw the hospice nurse in the facility once a week and was not sure about other supportive hospice staff. At exit, the facility was made aware that the cares written in the joint hospice and facility care plan were not implemented or corrected if not appropriate for the resident.
Failure to Hold and Document Care Plan Meetings
Penalty
Summary
The facility failed to hold care plan meetings with the interdisciplinary team at the time of the quarterly and annual revision of Resident #114’s care plans and failed to invite the resident or responsible party to those meetings. Resident #114’s quarterly MDS assessment was completed on 1/19/26 and the annual assessment was completed on 10/19/25, but the clinical record contained no evidence that a care plan meeting was held within 7 days or around the time of either assessment. On 04/23/26, the Social Worker Designee reviewed the record and confirmed the surveyor’s findings, then later provided documentation of care plan meetings for the past 9 months, which confirmed the surveyor’s findings.
Missed Scheduled Shower for Resident Requiring ADL Assistance
Penalty
Summary
The facility failed to ensure a resident who required assistance with ADLs received scheduled showers. Resident #133 stated during interview that showers were scheduled for Tuesdays and Fridays and reported not receiving the scheduled shower on Friday 04/17/2026. Review of the electronic medical record on 04/21/2026 showed documentation that the resident did not receive a shower on 04/17/2026. The Unit Manager stated staff are required to document showers in the electronic medical record and in the shower book, and review of the shower book showed a shower entry on 04/14/2026 but no entry for 04/17/2026. After being informed of the missing documentation, the Unit Manager stated the resident was capable of reporting whether a shower was received and acknowledged the resident likely did not receive the scheduled shower.
Failure to Provide Consistent Splinting for Hand Contracture
Penalty
Summary
Facility staff failed to provide appropriate care measures to prevent complications from a hand contracture for Resident #7, who had a left hand resting splint recommended by OT. During an interview, the resident stated the splint was only used occasionally and that help was sometimes needed to put it on; the surveyor observed the splint was not on the resident. On a later observation, the splint was again not on the resident, and the resident stated no one had offered to put it on. Review of OT documentation showed that the resident’s long-term goal was to wear the left resting hand splint for 8 hours per day to decrease the risk of further contracture and discomfort, and at OT discharge the resident tolerated the splint for 4 hours. There was no order or TAR for the left hand splint. The DON stated she would look into the concern, and the Functional Maintenance Assistant stated the resident was on the functional maintenance daily schedule; however, the reviewed log showed multiple blank weekends over a 5-month period, and the surveyor noted the resident was not offered the splint daily as recommended by OT.
Failure to Remove Discontinued IV Line and Maintain Dressing
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not followed when intermittent IV antibiotic infusions were administered to Resident #200. On 4/20/2026 at 9:15 AM, the resident stated that the IV antibiotics had been discontinued on Friday, but the IV line was still in the left upper arm. The surveyor observed bloody fluid in the IV tubing and on the bandage, which was dated 4/10/2026. At 9:22 AM, RN #3 stated the IV should have been removed when the antibiotics were finished, confirmed the dressing should be changed every 7 days, verified the current dressing had been in place for 10 days, and stated she would remove the IV. The DON acknowledged the concern on 04/21/2026 at 11:58 AM.
Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for Resident #138. The resident reported being hospitalized for a UTI, and the medical record showed an August 2025 hospitalization with a discharge summary recommending urology follow-up. However, the chart did not contain the urology consultation notes or the kidney and bladder ultrasound results that were later referenced. The DON stated the facility did not have the consultation notes and was trying to obtain them, and the surveyor noted that the resident’s record was incomplete and inaccurate. A progress note also incorrectly stated that the resident had been seen by the previous urology consult team and that the sonogram had been completed, while the results were not in the chart. The facility also did not maintain complete hospice documentation for Resident #6. The record showed hospice services were ordered, but the hospice documentation reviewed by the surveyor contained gaps, including periods with no documented visits and no nursing visits documented in February or March. A hospice nurse told the surveyor the resident was seen weekly by hospice nursing, while the SSA stated the hospice team came once a week, but the facility record did not reflect those visits. In addition, the EHR for Residents #4 and #8 showed a CMA repeatedly marked enhanced barrier precautions as "No" on multiple April entries, even though Staff #9 and the CMA confirmed the task should have been marked "Yes."
Unsafe Handling of Soiled Linen
Penalty
Summary
The facility failed to handle soiled linen safely in the Rosemary unit. During observation, a linen cart in the soiled utility room was seen with the lid off and unbagged linen overflowing onto the floor. An LPN stated the clothes should be bagged and believed the linen was supposed to be picked up once a week, and the DON later acknowledged the concern regarding unbagged, soiled linen in the soiled utility room.
Failure to Serve Timely, Proper-Temperature Meals in Accordance With Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide meals at regular, designated mealtimes in accordance with residents’ needs, preferences, and requests, as required by its own dietary policy on frequency of meals. The policy, last revised 10/2022, states that at least three daily meals will be provided at regular times comparable to normal community mealtimes and that the Dining Services Director will ensure each meal is served within the designated time frame. Surveyor observations in the Chesapeake dining room showed residents present from 12:10 PM to 1:00 PM for a posted lunch period of 12:15 PM to 12:30 PM, with several residents waiting without being served, some leaving the dining room and not returning, and one resident verbally expressing frustration about the delay. Interviews with cognitively intact residents confirmed that they had been waiting 40–45 minutes for lunch and that meals were not brought on time. Three sampled residents were specifically affected. One resident with type 2 diabetes mellitus with hyperglycemia, pancreatitis, lung disorder, acute kidney failure, and mineral metabolism disorder reported waiting over forty minutes for lunch and stated that staff never brought food on time. Another resident with a displaced fracture, central cord syndrome sequela, and anxiety disorder reported waiting over 45 minutes for lunch, stated that weekends were worse, and that food was usually cold by the time it was served; this resident also reported staff becoming upset when asked to reheat meals. A third resident, the Resident Council President with anxiety disorder, depression, and hypo-osmolality, reported that for the last six months meals had been served late, often cold, and that staff displayed negative or disrespectful demeanor when residents requested reheating. Staff interviews revealed that meals were frequently late due to dietary staffing shortages and logistics problems, while observations showed that there were sufficient nursing and non-nursing staff available to assist dietary staff when needed.
Unsanitary, Leaking Toilets and Poor Bathroom Maintenance for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain a functional, sanitary, and comfortable bathroom environment for five residents whose rooms had toilets with rust, black mildew-like buildup, missing caulk/sealant, instability, and active water leakage. Facility policies on Resident/Patient Room Cleaning and Safe and Homelike Environment required regular cleaning and disinfection of restrooms, including toilets and surrounding areas, and provision of housekeeping and maintenance services as necessary to maintain a sanitary, orderly, and comfortable environment. Despite these policies, surveyors observed that the toilets in the rooms of five residents had a rust stain approximately five inches wide and seven inches long, black discoloration around the toilet seal resembling mildew, missing caulk/sealant, and unsteady commodes that shifted side to side, with water leaking from the base. The affected residents had multiple medical diagnoses and varying levels of cognitive function and dependence on staff for ADLs, including toileting. One resident had Type II diabetes, dysphagia, hyperlipidemia, depression, hypertension, GERD, and frequent bowel and bladder incontinence, and was cognitively intact and able to report that the toilet rust stain had been present for a while, that housekeeping cleaned daily but the stains remained, that the toilet moved and leaked where the caulking was missing, and that no one should live with a dirty bathroom. Another resident with dementia, hyperlipidemia, hypertension, GERD, major depressive disorder, dysphagia, and frequent incontinence, who used a walker and went to the bathroom independently, reported that the toilet leaked and expressed concern about slipping and falling, though they did not know how long the leakage had been occurring. Other residents involved had conditions such as dementia, chronic kidney disease, hemiplegia, aphasia, schizophrenia, bipolar disorder, COPD, and failure to thrive, and were dependent on staff for toileting and transfers, yet their toilets were also found with rust, mildew-like buildup, missing caulk, and leakage. Staff interviews revealed inactions and incomplete follow-through that contributed to the ongoing unsanitary and nonfunctional bathroom conditions. A housekeeper with 16 years of experience stated they clean the bathroom, including the toilet bowl and the area behind the toilet, and are expected to report room problems to a supervisor so a work order can be placed, but acknowledged they did not see the rust stain behind the toilet, could not remove a stain, and simply left it, planning only to inform the supervisor if it happened again. The Environmental Services Manager stated that rooms are expected to be cleaned daily and that only about 10% of rooms receive a complete daily check, and reported having seen caulk/sealant issues but not rust stains. The Maintenance Supervisor, in the role for two months, stated they noticed the rust stain two to three weeks earlier, notified housekeeping to clean again, and asked a technician to complete caulking, but did not perform any follow-up to ensure the work was completed. These actions and omissions allowed the rust, mildew-like buildup, missing caulk, toilet instability, and water leakage to persist in resident bathrooms in violation of facility policies and regulatory expectations for a safe, clean, and comfortable environment.
Failure to Prevent Resident Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a geriatric nursing assistant. The incident occurred when the Business Office Director and the Admission Director observed the nursing assistant hitting a resident with a small, gray bag. The resident involved in the incident had a medical history of Alzheimer's Disease and schizophrenia and was non-verbal during the surveyor's interview. The abuse was substantiated by the facility's investigation. The incident was reported to the Maryland Board of Nursing, and the nursing assistant was suspended and subsequently terminated following the investigation. The resident was assessed after the incident and showed no signs of pain, trauma, skin discoloration, or psychological trauma. The deficiency highlights a failure in the facility's responsibility to prevent abuse and ensure the safety and well-being of its residents.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to treat residents with dignity by not ensuring privacy for two residents during daily care. One resident with a Foley catheter had their urinary drainage bag uncovered and visible from the hallway, as it was attached to the side of the bed facing the open door. The contents of the bag were observable to anyone passing by, compromising the resident's privacy and dignity. Another resident was observed with lower extremity dressings exposed to the hallway while lying in bed near the room entrance. The dressings, dated from the previous shift, were visible to other residents and visitors. Despite staff being notified of the issue, the resident continued to have their dressings exposed during subsequent observations, and the resident reported that staff never covered their feet, allowing others to see them.
Failure to Offer Opportunity to Formulate Advance Directives
Penalty
Summary
Surveyors determined that the facility failed to provide residents and/or their representatives with the opportunity to formulate an advance directive. During record reviews, it was found that three residents did not have advance directives documented in their medical records. Additionally, there were no progress notes indicating that these residents or their representatives had been presented with the option to complete an advance directive. The Director of Social Services confirmed that these residents did not have advance directives in place and that there was no documentation showing that the opportunity to complete one had been offered.
Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to maintain a clean, safe, and homelike environment for residents. Observations included marred and scraped walls, large unpainted spackled areas, and dirty floors with food and trash present in resident rooms. In one instance, a resident was unable to reach their trash can due to its placement. Additional issues included a loose bathroom faucet and separated baseboard, as well as bathrooms with dried rust-colored and brown substances around toilets and on walls. Broken fixtures, such as a toilet paper holder, and stained ceiling tiles were also noted. In one room, two cups containing a clear yellow substance with a strong ammonia, urine-like odor were found on the floor near a resident's bed. These deficiencies were observed in the rooms and bathrooms of several residents, with some residents directly reporting maintenance issues to surveyors. The findings were communicated to facility leadership, including the Administrator and DON, during the survey process. The report documents the specific environmental and cleanliness concerns that were present at the time of the survey, as observed and reported by both residents and staff.
Failure to Accurately Document and Administer Medications
Penalty
Summary
Nursing staff failed to follow professional standards of practice during medication administration for two residents. In one instance, a resident refused a physician-ordered Lidocaine Patch during the medication pass, but the medication administration record (MAR) inaccurately documented the patch as given rather than refused. In another case, a nurse prepared multiple tablets for a resident but stated that Zinc 220mg was unavailable and could not be administered. Despite this, the MAR indicated that the Zinc was given, and also showed documentation for several other medications as administered, even though the surveyor did not observe these medications being given. The MAR lacked documentation that the medication was unavailable, including the required date, initials, and time. During an interview, the nurse confirmed that she had signed off on medications as given when, in fact, they were not administered. These actions resulted in inaccurate documentation of medication administration for both residents.
Delay in Addressing Resident Request for Feeding Tube Removal
Penalty
Summary
A deficiency was identified when a resident with a percutaneous enteral gastric (PEG) feeding tube expressed a desire to have the tube removed after successfully tolerating a regular diet with nectar thick liquids for several months. The resident reported to staff and the surveyor that the feeding tube was no longer being used for nutrition, only for hydration, and that he had been waiting for three months for its removal. Despite the resident's repeated requests and the fact that he was eating well by mouth, the facility did not schedule the recommended modified barium swallow study (MBSS) in a timely manner to assess the resident's eligibility for tube removal. Medical record reviews confirmed that the resident had completed speech therapy with positive results and had a previous MBSS indicating improved swallowing function, with a recommendation for a repeat study within two months. However, there was no evidence that the facility scheduled this follow-up MBSS until after the surveyor's inquiry. Documentation showed that the resident's ability to swallow was unimpaired and that the DON and administrator had been notified of the resident's wishes, but the necessary assessment to proceed with tube removal was delayed.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
Facility staff failed to maintain a medication error rate below 5 percent, as evidenced by 6 errors out of 29 observed medication administration opportunities. During medication administration, an LPN prepared an insulin injection for a resident and initially drew up 30 units instead of the ordered 24 units. The error was corrected only after surveyor intervention, and the correct dose was administered. In another instance, a resident refused a prescribed lidocaine patch, but the LPN documented the medication as administered on the medication administration record (MAR). Further observations revealed that the same LPN prepared medications for another resident but did not administer several ordered medications, including zinc, fluocinonide ointment, protein liquid, refresh teardrops, and Ocusoft lid scrub. Despite this, the LPN documented on the MAR that these medications were given. The LPN later confirmed during an interview that the medications were not administered as documented and acknowledged the insulin dosing error. These actions contributed to a medication error rate exceeding the regulatory threshold.
Significant Medication Error in Insulin Administration
Penalty
Summary
During a medication administration observation, a nurse prepared an insulin injection for a resident with diabetes by drawing 30 units of insulin from a prefilled insulin pen into a syringe, despite the provider's order specifying 24 units. The nurse was questioned by the surveyor about the correct dosage, at which point she acknowledged the error and adjusted the dose to 24 units before administering the medication. The resident's medication administration record confirmed the order for 24 units of Basaglar Tempo insulin to be given subcutaneously in the morning. The nurse involved reported having one year of nursing experience.
Expired Medications Found in Storage Room
Penalty
Summary
Surveyors observed that the facility failed to properly store medications in accordance with accepted professional principles. During an inspection of one medication storage room, two bags of intravenous drugs, a COVID self-test kit, and an insulin injection pen were found with expiration dates that had already passed. The expired items were present in the storage area at the time of observation, indicating that staff had not discarded them as required. The assistant director of nursing confirmed during an interview that staff are expected to dispose of expired medications, but these items had not been removed prior to the surveyor's visit.
Failure to Provide Lactose-Free Milk to Resident with Dietary Intolerance
Penalty
Summary
A resident with lactose intolerance was not provided with lactose-free milk as required by their dietary needs. During an observation, the resident reported receiving 2% milk instead of the Lactaid milk specified on their menu sheet, and stated that this error occurred frequently. The menu sheet confirmed that Lactaid milk was ordered, but the incorrect milk was served. On a subsequent day, the resident did not receive any milk, and the milk choice was crossed out on the menu sheet, which was verified by the surveyor. The issue was brought to the attention of a Geriatric Nursing Aide, and the Dietary Manager later acknowledged the problem, attributing it to a possible supply issue.
Persistent Unsanitary Odor in Facility Unit
Penalty
Summary
Surveyors observed a persistent, strong ammonia urine-like odor throughout the hallways and residents' rooms on one unit of the facility during multiple observation rounds. Staff, including the unit manager, nursing home administrator, and director of nursing, were interviewed and acknowledged the presence of the odor. Despite being made aware of the issue, the odor remained present during subsequent observations, indicating that the environment was not maintained in a sanitary or comfortable condition for residents, staff, and the public. No specific residents or their medical histories were mentioned in relation to the deficiency. The deficiency was limited to one of five units observed during the survey.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,184 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Tuckerman Rehabilitation And Healthcare Center | 0.5 mi | ★★★★★ | 5 | 0 |
| Maplewood Park Place | 0.7 mi | ★★★★★ | 0 | 0 |
| Montcare At Bethesda | 1 mi | ★★★★★ | 14 | 0 |
| Carriage Hill Bethesda | 1.3 mi | ★★★★★ | 23 | 0 |
| Hebrew Home Of Greater Washington | 2.1 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sterling Care Bethesda.
100% money-back within 48 hours.
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.