Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Tuckerman Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Two residents were discharged without appropriate reasons or proper documentation. One resident with terminal cancer was told hospice care could not be provided at the facility, despite the admission contract stating otherwise, and the family was not informed of service limitations. Another resident with advanced dementia was discharged due to poor rehab participation and the need for a memory care unit, but there was no documentation that the facility could not meet their needs. In both cases, regulatory requirements for discharge were not met, and staff interviews confirmed discharges were based on therapy participation rather than regulatory criteria.
The facility did not provide the required 30-day written discharge notices to two residents who were being discharged, instead issuing only a Notice of Medicare Non-Coverage (NOMNC). In both cases, the discharges were initiated by the facility due to changes in care needs, and interviews confirmed that neither resident nor their representatives received the mandated 30-day notice explaining the reason for discharge.
A resident's representative requested that the resident remain in the facility to receive hospice care, but staff informed the representative that hospice could not be provided on-site and proceeded with discharge plans. Despite the facility having a contract with a hospice provider and being capable of providing hospice services, staff preferred to discharge residents needing hospice or LTC. The representative appealed the discharge and attempted to find alternative placement, but ultimately felt pressured to take the resident home.
A resident was administered quetiapine and PRN lorazepam for behavioral symptoms without proper documentation of behavior monitoring, nonpharmacological interventions, or attempts at gradual dose reduction. The PRN psychotropic order lacked a required 14-day stop date, and the consent for psychotropic use was signed on admission without evidence of exhausted nonpharmacological approaches. Staff interviews confirmed inadequate documentation and inappropriate diagnoses for medication use.
A resident with advanced cancer diagnoses and in need of end-of-life care was admitted for rehabilitation, but neither the resident nor their representative was informed in writing that the facility did not provide hospice or LTC services. The facility's admission materials did not disclose these limitations, and the family was only verbally notified when discharge planning for hospice was initiated.
The facility did not complete thorough investigations into two separate abuse allegations, as required. In both cases, the DON confirmed that neither staff nor resident interviews or statements were obtained or documented as part of the investigation.
Inappropriate Discharge and Inadequate Documentation for Two Residents
Penalty
Summary
The facility discharged two residents without appropriate reasons and failed to properly document the discharges, as required by regulation. For one resident with metastatic skin cancer and multiple comorbidities, the facility issued a Notice of Medicare Non-Coverage (NOMNC) and informed the family that hospice care could not be provided at the facility, despite the admission contract stating hospice care was available. The family was not informed of any service limitations at admission and expressed concerns about the discharge, especially since the resident’s spouse had dementia and could not provide adequate care at home. The facility staff, including the Social Services Director (SSD) and Director of Nursing (DON), stated the resident was being discharged due to the need for hospice care, but there was no documentation that the resident met any regulatory criteria for facility-initiated discharge. The facility also failed to provide documentation supporting their claim that the discharge was family-initiated. For the second resident, who had advanced dementia and severe cognitive impairment, the facility issued a NOMNC and planned for discharge due to poor participation in rehabilitation and the need for a memory care unit. The attending physician noted the resident was not a good candidate for the facility’s short-term rehabilitation program, but there was no documentation that the facility was unable to meet the resident’s needs or that the resident met the regulatory requirements for discharge. The family was not made aware of any limitations in the facility’s services and struggled to find an appropriate placement due to a pending Medicaid application. Interviews with facility staff confirmed that discharges were often initiated when residents plateaued in therapy or were no longer participating, regardless of whether regulatory discharge criteria were met. The facility’s admission contract and agreements with hospice providers indicated that hospice care could be provided, contradicting staff statements to families. The lack of proper documentation and failure to meet regulatory requirements for discharge were confirmed by the Nursing Home Administrator and DON during the survey.
Failure to Provide Required 30-Day Discharge Notices
Penalty
Summary
The facility failed to provide a required 30-day written notice of discharge to two residents who were being discharged from the facility. In the first case, the Social Services Director (SSD) attempted to issue a Notice of Medicare Non-Coverage (NOMNC) to the resident's family, indicating the end of Medicare Part A coverage and a planned discharge date. However, the family declined to sign the NOMNC, and the SSD explained that the facility could not provide hospice care. Despite this, there was no documentation that a 30-day written discharge notice, including the reason for discharge, was provided to the resident or their representative. The resident's representative confirmed that they did not receive such notice and only received the NOMNC, which was confusing as the resident still had Medicare days remaining. The SSD and DON both confirmed that the discharge was initiated by the facility due to the need for hospice care, not by the family, and that the required 30-day notice was not issued. In the second case, the SSD documented issuing a NOMNC to the family of another resident, with services ending shortly thereafter and a discharge to the community planned. The family appealed the NOMNC, but there was no evidence in the medical record that a 30-day discharge notice was provided to the resident's representative. Interviews with the NHA, DON, and SSD confirmed that the resident was discharged because it was determined they would benefit from a memory care unit, and that only the NOMNC was issued, not the required 30-day discharge notice. These findings were reviewed with facility leadership.
Failure to Honor Resident Representative's Request for Hospice Care
Penalty
Summary
The facility failed to honor the wishes of a resident's representative by not allowing the resident to remain at the facility while receiving hospice services. The resident's representative was informed by the Social Services Director (SSD) that the facility would discharge the resident because they could not provide hospice care on-site, despite the representative's request for the resident to stay and receive hospice care. The representative appealed the discharge twice and attempted to find another facility, but was denied due to the resident's wound care needs. Ultimately, the representative felt pressured by staff to take the resident home. Medical record review showed that the SSD attempted to issue a Notice of Medicare Non-Coverage (NOMNC), but the family did not sign it, and the SSD reiterated that hospice care could not be provided at the facility. A review of the facility's contract with a hospice provider revealed that the facility did have an agreement in place to provide hospice services to residents. Interviews with the SSD, DON, and Nursing Home Administrator confirmed that the facility preferred to discharge residents who required hospice or long-term care, even though they were capable of providing hospice services. The DON and NHA both stated that residents were discharged when they needed hospice care, and the NHA confirmed that the facility would only provide hospice care for a few days before discharging the resident to another setting. The facility was dually certified for rehabilitation and long-term care, but did not honor the resident representative's request for continued care with hospice services.
Failure to Prevent Unnecessary Psychotropic Medication Use and Chemical Restraints
Penalty
Summary
Facility staff failed to ensure that residents were free from unnecessary psychotropic medications and chemical restraints, as well as to limit PRN psychotropic medications to 14 days. For one resident reviewed for discharge, the medical record showed ongoing administration of quetiapine for sundowning and lorazepam as needed for anxiety, with both medications continued for several months. The informed consent for psychotropic use was signed on the day of admission, stating that all nonpharmacological interventions had been exhausted, but there was no evidence that such interventions were attempted or documented prior to medication administration. Physician orders for the resident included lorazepam PRN without a 14-day stop date and quetiapine with an increased dosage for a diagnosis that was not appropriate. There was no documentation of behavior monitoring or attempts at gradual dose reduction for these medications. The psychiatric NP documented continued use of quetiapine for behavior modification, but behavior notes did not reflect monitoring of the targeted behaviors. The medication administration record showed multiple administrations of lorazepam by the same RN, with no documentation of the reasons for administration or nonpharmacological interventions attempted beforehand. Interviews with facility staff, including the attending physician, RN, and DON, confirmed that documentation was lacking regarding the behaviors leading to medication use and the use of nonpharmacological interventions. The DON acknowledged that the consent form was not appropriate and that behavior monitoring and documentation were not adequately performed. The staff also recognized that the PRN order for lorazepam should have included a 14-day stop date, and that the diagnosis for quetiapine was not appropriate.
Failure to Disclose Service Limitations for Hospice and Long-Term Care
Penalty
Summary
The facility failed to inform residents and their representatives about limitations in the care services provided, specifically regarding the inability to provide hospice or long-term care. A review of the admission packet signed by a resident showed that hospice services were listed as provided, and there was no indication of any service limitations. The facility's documentation did not state that residents would be discharged if they required hospice or long-term care, nor did it clarify that only rehabilitation services were offered. Interviews revealed that the resident's representative was not informed at admission about these limitations and only learned of them when the facility initiated discharge planning after the resident's condition declined and hospice care was needed. The resident in question had multiple serious diagnoses, including metastatic cancers and was considered to be at end-of-life shortly after admission. Despite this, the facility proceeded with discharge planning for hospice care, informing the family that the resident could not remain at the facility for hospice services. The Social Services Director and Nursing Home Administrator confirmed that residents needing hospice or LTC were assisted in finding new placement, but this was not documented in the admission materials and was only communicated verbally. The attending physician also confirmed that such residents were transferred elsewhere, further evidencing the lack of written disclosure to residents and their representatives.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse for two residents. In the first case, the facility's investigation into an abuse allegation did not include interviews with staff or the collection of staff statements. The Director of Nursing (DON) confirmed during an interview that these steps were not completed and was unable to locate any staff interviews or statements related to the incident. In the second case, the investigation into another abuse allegation similarly lacked interviews with both residents and staff, as well as the collection of their statements. The DON again confirmed the absence of these critical investigative components and was unable to provide any documentation of interviews or statements when requested by the surveyor.
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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.
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Nursing homes near North Bethesda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sterling Care Bethesda | 0.5 mi | ★★★★★ | 24 | 0 |
| Montcare At Bethesda | 1.1 mi | ★★★★★ | 14 | 0 |
| Maplewood Park Place | 1.2 mi | ★★★★★ | 0 | 0 |
| Hebrew Home Of Greater Washington | 1.7 mi | ★★★★★ | 5 | 0 |
| Carriage Hill Bethesda | 1.8 mi | ★★★★★ | 23 | 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.