Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Montcare At Bethesda during CMS and state inspections, most recent first.
A resident developed new bilateral buttocks abscesses, which were documented in progress notes and wound assessments. However, the care plan was not updated to address these new wounds, as confirmed by review of care plan revision history and staff interviews, including with the DON and a nurse practitioner.
A resident with intact cognitive function was subjected to a straight catheterization by two nurses without a physician's order or the resident's consent. Despite facility policy requiring both an order and consent for such procedures, the nurses proceeded based on their own judgment, and the DON later confirmed that no order had been obtained.
A resident with a Stage 3 pressure ulcer did not receive wound care as recommended by the wound care provider. The facility failed to enter the correct treatment orders and did not document wound care completion for several days. The wound worsened to Stage 4, and the wound care provider recommended hospital transfer. Interviews with the DON and Unit Manager confirmed the discrepancy between the provider's recommendations and the facility's actions.
A resident's medical records were inaccurately documented when staff signed off daily completion of a monthly mediport flush order, and continued to document the procedure as completed even after the mediport was removed. The DON confirmed that these sign-offs were inappropriate and did not reflect actual care provided.
The facility failed to notify the Ombudsman of a resident's transfer to an acute care facility and did not provide written notification to another resident or their representative regarding hospital transfers. The Director of Nursing acknowledged the expectation to notify the Ombudsman, and the Divisional Director of Quality Assurance stated that written notices should be provided, but no evidence was found in the records.
A facility failed to notify a resident or their representative in writing about the bed hold policy during hospital transfers. The resident's clinical record lacked documentation of this notification, and the Business Office Manager confirmed the absence of evidence. The facility could not provide documentation at the exit conference.
A resident found keys to a medication cart on the floor, indicating a lapse in medication security. Additionally, two insulin pens were improperly stored in a medication cart drawer instead of being refrigerated as required. The DON and a staff nurse acknowledged these findings.
Surveyors identified improper food storage in the kitchen, including expired Red Cooking Wine and Concord Grape Jelly without proper dating in the refrigerator. Additionally, expired Crispy Rice Cereal and Confectioners Sugar were found in the dry storage room. These items were confirmed by staff and removed for disposal.
A resident with left side paralysis and limited use of the right arm was unable to use the call bell due to its inaccessibility and inappropriate design. The resident relied on a roommate to alert staff for assistance. Despite frequent rounding, staff did not identify the issue until the survey, highlighting a failure to accommodate the resident's needs.
A facility failed to transmit MDS assessments within the required 14 days for a resident, resulting in a delay of over 120 days. The MDS Coordinator acknowledged the error, stating that assessments are usually transmitted weekly or twice a week. The President of Clinical Services was notified of the oversight.
The facility failed to revise care plans for two residents receiving specific medications. One resident's care plan lacked documentation for psychotropic medications, while another resident's care plan did not address monitoring for anticoagulant therapy. Interviews with staff confirmed the absence of these care plans, which were expected to be in place.
A facility failed to provide appropriate care for a resident with a G-tube. During a medication pass, a staff member flushed the resident's G-tube without checking for proper placement, contrary to the facility's policy. The staff member acknowledged the oversight, which was observed by a surveyor.
A resident experienced inadequate respiratory care when their oxygen tubing was found disconnected and water was observed in the tubing. The LPN was unaware of the issue, and the ADON initially attributed it to condensation. Despite attempts to resolve the problem, the resident reported not using the oxygen overnight due to water dripping from the nasal cannula. The issue was later identified as a faulty oxygen concentrator, which was replaced.
The facility failed to implement non-pharmacological pain interventions and did not adhere to physician orders for PRN pain medications for two residents. Non-pharmacological interventions were not documented, and pain medications were administered outside prescribed parameters. Staff interviews revealed inconsistencies in following pain management protocols and documentation practices.
A facility failed to deliver meals at appropriate temperatures, as observed during a survey. A resident complained about cold meals, and a test tray showed scrambled eggs and hashbrowns at 90 and 95 degrees Fahrenheit, below the expected 120 degrees. The Kitchen Manager confirmed the deficiency, and the Food Service Director noted that plate warmers were ordered.
Facility staff failed to follow infection control practices during medication administration and dressing changes. A nurse administered medications and took a resident's blood pressure without performing hand hygiene. Another staff member changed a resident's G-tube dressing without changing gloves or sanitizing hands. Both staff members acknowledged their lapses when questioned by surveyors.
A survey identified a deficiency in a call system within a shower room, where a call bell device lacked a necessary cord for activation. This issue was confirmed by the Maintenance Technician and the NHA during a facility tour.
Failure to Update Care Plan for New Wounds
Penalty
Summary
A deficiency was identified when the facility failed to update the comprehensive care plan for a resident who developed new wounds. Record review showed that the resident developed abscesses on the bilateral buttocks, as documented in a Skin and Wound Note and a wound assessment. Despite these findings, the resident's care plan was not updated to address the new wounds. The care plan revision history confirmed that no new interventions or goals were added after the wounds were identified. Interviews with facility staff, including a nurse practitioner and the Director of Nursing (DON), confirmed that the wounds were present and that the care plan had not been updated accordingly. The DON acknowledged that the responsibility for updating care plans at the time belonged to a wound treatment nurse, who failed to make the necessary updates. The lack of timely care plan revision was confirmed by both documentation review and staff interviews.
Catheterization Performed Without Physician Order or Consent
Penalty
Summary
A deficiency occurred when nursing staff performed a straight catheterization on a resident without obtaining a physician's order or the resident's consent. The incident involved two nurses who, during the early morning hours, inserted a catheter to collect a urine sample after the resident declined to walk to the bathroom. The resident, who was cognitively intact as indicated by a BIMS score of 15, reported that the procedure was done without explanation or consent, leading the resident to feel violated and contact local authorities. Review of the medical record showed that while there was a physician's order for laboratory tests including urinalysis, there was no specific order for straight catheterization. Facility policy required a physician's order for all catheterizations, and staff interviews confirmed that both an order and resident consent were necessary for the procedure. The DON acknowledged that the catheterization was performed based on nursing judgment rather than a physician's directive, in direct contradiction to facility policy.
Failure to Follow Wound Care Provider Recommendations for Pressure Ulcer Treatment
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate wound care for a resident with a Stage 3 pressure ulcer in the sacral area. The wound care provider made specific recommendations for wound treatment, including the use of Collagen and later Dakins solution with fluffed gauze, zinc oxide paste, and transparent film, to be applied twice daily. However, these recommendations were not entered into the resident's treatment orders or the Treatment Administration Record (TAR). Instead, the facility ordered a different treatment regimen, including cleansing with normal saline instead of Dakins solution and applying the treatment only once daily on certain days, which did not match the wound care provider's instructions. Further review revealed that wound care was not documented as completed for several days, and when it was documented, it was not done according to the recommended frequency. Interviews with the DON and the Unit Manager confirmed that the wound care provider's recommendations were not followed and that the orders in the TAR differed from those recommendations. The resident's wound worsened from Stage 3 to Stage 4, and the wound care provider ultimately recommended hospital transfer for further management.
Inaccurate Medical Record Documentation for Mediport Care
Penalty
Summary
The facility failed to ensure the accuracy of medical records for one resident who had a mediport in place. Medical record review showed that there was an order to flush the resident's implanted port monthly, which was incorrectly documented as completed daily over several months, rather than only on the scheduled date. Additionally, after the mediport was surgically removed, staff continued to sign off the order as completed for several days, despite the port no longer being present. The Director of Nursing confirmed that the order should not have been signed off unless the procedure was actually performed and that documentation should have ceased after the port's removal.
Failure to Notify Ombudsman and Provide Written Transfer Notices
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's transfer to an acute care facility and did not provide written notification to another resident or their representative regarding hospital transfers. Specifically, the facility did not inform the Ombudsman about the transfer of a resident to a hospital emergency room on a specified date. This omission was discovered during a review of the Ombudsman notification records, which lacked documentation of the transfer. The Director of Nursing acknowledged that the facility's expectation is to notify the Ombudsman of all resident transfers. Additionally, the facility did not provide written notification to a resident or their representative for multiple hospital transfers. The clinical record review revealed no documentation of written notices for transfers on specific dates. The Divisional Director of Quality Assurance stated that the nursing staff is expected to notify residents or their representatives verbally and provide a written hospital transfer/discharge form. However, a review of the binder where these forms are kept showed no evidence of written notices for the resident's transfers. At the time of the exit conference, the facility could not provide evidence of written notification for these transfers.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident or the resident's representative in writing about the bed hold policy when the resident was transferred to an acute care facility. This deficiency was identified during the annual survey for one of the three residents reviewed for hospitalizations. Specifically, the clinical record of the resident showed transfers to the hospital on two occasions, but there was no documentation that the bed hold policy was communicated in writing to the resident or their representative. An interview with the Business Office Manager confirmed the absence of evidence that the bed hold policy was provided in writing for the hospital transfers. At the time of the exit conference, the facility was unable to present any documentation to show compliance with the requirement to notify the resident or their representative about the bed hold policy.
Medication Security and Storage Deficiencies
Penalty
Summary
The facility failed to maintain a secure system for medication management, as evidenced by an incident involving a resident who found a set of keys belonging to a medication cart on the hallway floor. The keys were handed over to the surveyor by the resident, who stated they were found on the 1st floor nursing unit. During an interview, the Nursing Home Administrator and the Director of Nursing were informed about the missing keys, and it was confirmed that they were unaware of the situation. An observation of the medication cart revealed that the narcotic counts were accurate and matched the narcotic log, indicating no discrepancies in the medication inventory. Additionally, the facility did not store medications properly, as observed during a medication storage check on the Embassy Unit. Two insulin pens, one for Humalog Kwik Pen and another for Glargine Solostar, were found in a basket in the 3rd drawer of the medication cart, despite having pharmacy labels indicating they should be refrigerated until opened. The Director of Nursing and a staff nurse acknowledged the surveyor's findings, confirming the improper storage of these medications.
Improper Food Storage in Kitchen
Penalty
Summary
During a recertification survey, surveyors observed deficiencies in the storage of food items in the kitchen of the facility. On the initial tour of the kitchen, surveyors found a bottle of Red Cooking Wine with an open date of 8/15/24 and a dispose date of 9/15/24, as well as an opened 48 oz glass container of Concord Grape Jelly without any open or dispose date in the food prep refrigerator. These items were confirmed by a cook to be improperly stored and were subsequently removed for disposal. Further observations in the dry storage room revealed two unopened bags of Crispy Rice Cereal with a use-by date of 10/2/24 and five unopened boxes of Confectioners Sugar with a use-by date of 2/1/22. The Kitchen Manager confirmed these items were past their use-by dates and removed them from the shelf for disposal.
Inadequate Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident by not ensuring that a call bell was kept within reach and by not providing the appropriate type of call bell device for the resident's use. During the annual survey, it was observed that a resident with left side paralysis and severe limited use of the right arm was unable to use the call bell. The resident had to rely on a roommate to activate the call bell for assistance. The call bell was found resting on the resident's chest but tucked under the blanket, making it inaccessible. Further observations revealed that the call bell was placed on the headboard, out of the resident's reach. The resident's LPN confirmed that the resident was unable to activate the call bell and that the roommate often alerted staff when assistance was needed. Despite frequent rounding by nursing staff, the issue was not identified until the survey. The deficiency was evident as the resident was dependent for all care, and the facility did not provide a suitable call bell device to accommodate the resident's needs.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments within the required 14 days of completion for a resident. Specifically, the MDS assessment for a resident with a discharge date was completed but not transmitted to the Centers for Medicare and Medicaid Services' (CMS) Internet Quality Improvement and Evaluation System (iQIES) for over 120 days. This delay was identified during a record review conducted as part of the annual survey. During an interview, the MDS Coordinator acknowledged the requirement to transmit MDS assessments within 14 days and confirmed that the assessment in question was not submitted due to an error. The coordinator stated that assessments were typically transmitted weekly or twice a week, but this particular assessment was overlooked. The President of Clinical Services was informed of the oversight, confirming the deficiency in the facility's process for timely transmission of MDS assessments.
Failure to Revise Care Plans for Medications
Penalty
Summary
The facility failed to ensure that care plans were revised for two residents who were receiving specific medications. For one resident, the Medication Administration Record indicated the use of psychotropic medications, including busPIRone HCl and Seroquel. However, a review of the resident's care plan revealed that there was no care plan in place for these psychotropic medications. The Divisional Director of Quality Assurance confirmed that it was the facility's expectation to have a care plan with a focus, goal, and interventions for psychotropic medications. Another resident was receiving Heparin Sodium injections for Deep Vein Thrombosis prophylaxis, but there was no care plan developed to monitor for bruising and bleeding related to anticoagulant therapy. Interviews with an LPN and a Unit Manager revealed that the care plan for blood thinners should have been in the electronic system, but they were unable to locate it. The Assistant Director of Nursing confirmed that a care plan should have been initiated for residents on blood thinners, and it was the responsibility of the Unit Managers to develop these care plans.
Failure to Verify G-Tube Placement Before Flushing
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident receiving tube feedings. During a medication pass, a surveyor observed a staff member flushing a resident's gastrostomy tube (G-tube) with water without first checking for proper placement. The staff member admitted to not verifying the G-tube placement by aspirating the stomach contents before administering the flush, which is against the facility's policy. The facility's policy, revised earlier in the year, mandates that the placement and functioning of a feeding tube be verified before any feeding, flushing, or medication administration.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, as observed by a surveyor. The deficiency was identified when the surveyor noticed the resident's oxygen tubing and nasal cannula disconnected and lying on the floor, with water droplets moving inside the tubing. The resident's son reported that water had backed up from the oxygen concentrator. The humidifier bottle and tubing were not dated, indicating a lack of adherence to proper procedures. An LPN was unaware of the issue, as she had not yet conducted her morning assessment. The Assistant Director of Nursing (ADON) was informed of the situation and observed the water in the tubing, attributing it to condensation from the concentrator being near a room heater. Despite moving the concentrator and changing the tubing, the problem persisted, as the resident reported not using the oxygen overnight due to water dripping from the nasal cannula. The ADON later determined the issue was with the oxygen concentrator itself, which was subsequently replaced. The surveyor later confirmed that the new equipment was correctly dated, but the initial failure to provide proper respiratory care was evident.
Deficiency in Pain Management and Documentation
Penalty
Summary
The facility failed to develop and implement non-pharmacological interventions for pain management and did not ensure that pain medication was administered in accordance with professional standards of practice. This deficiency was identified during an annual survey for two residents who were reviewed for pain management. The records for these residents showed that non-pharmacological interventions were not documented in the Medication Administration Record (MAR), Treatment Administration Record (TAR), progress notes, or care plans. Interviews with staff, including Licensed Practical Nurses (LPNs), Unit Managers (UMs), and the Assistant Director of Nursing (ADON), revealed a lack of clarity and consistency in documenting and implementing non-pharmacological interventions. Additionally, the facility staff did not adhere to the pain parameters specified in the physician orders for administering PRN pain medications. For one resident, Oxycodone was administered despite a pain level of 3, which did not meet the criteria for moderate pain as per the physician's order. Similarly, another resident received Acetaminophen and Tramadol for pain levels that did not align with the prescribed parameters for moderate and severe pain. The MAR and nursing progress notes indicated discrepancies between the recorded pain levels and the administration of pain medications. Interviews with nursing staff, including Registered Nurses (RNs) and UMs, highlighted inconsistencies in following the facility's pain management protocols. The ADON confirmed that a standard pain scale was used, but the pain parameters in the physician orders were not consistently followed by the nurses. The facility's process for documenting pain levels and the effectiveness of pain medications was not adequately implemented, leading to the administration of pain medications outside the prescribed parameters.
Failure to Deliver Meals at Appropriate Temperature
Penalty
Summary
The facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This deficiency was identified during a surveyor's observation and interviews with residents and facility staff. A complaint was reviewed where a resident alleged that all meals were delivered cold. During a breakfast tray observation, it was noted that the plates on the meal cart did not have bottom plate warmers to maintain warmth. The surveyor, along with the Kitchen Manager, observed the meal cart delivery process, and it was found that the scrambled eggs and hashbrowns on the test tray were at temperatures of 90 and 95 degrees Fahrenheit, respectively, which were below the expected 120 degrees Fahrenheit for hot foods. The Food Service Director later confirmed that 24 plate warmers had been ordered.
Infection Control Lapses in Medication Administration and Dressing Changes
Penalty
Summary
The facility staff failed to adhere to infection control practices during medication administration and dressing changes, as observed by surveyors. In the first instance, a Registered Nurse, identified as Staff #8, administered medications to a resident in a semi-private room without performing hand hygiene afterward. The nurse then proceeded to take another resident's blood pressure without sanitizing hands, despite acknowledging the usual practice of wearing gloves. In the second instance, Staff #9, while wearing gloves, removed a contaminated dressing from a resident's G-tube site and immediately reached for a clean dressing without changing gloves or performing hand hygiene. This oversight was acknowledged by Staff #9 during an interview with the surveyor.
Deficiency in Call System Functionality in Shower Room
Penalty
Summary
During a recertification survey, it was observed that the facility staff failed to ensure that a call system in a shower room was fully functional. Specifically, a call bell device mounted on the wall within one of the shower stalls in the first-floor central shower room was missing a cord. This cord is essential for residents to activate or deactivate the call light, particularly in situations where a resident might fall and be unable to reach the button on the mounted device. The deficiency was confirmed during an initial tour by surveyors and further verified by the Maintenance Technician and the Nursing Home Administrator.
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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 Bethesda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sterling Care Bethesda | 1 mi | — | 3 | 0 |
| Maplewood Park Place | 1 mi | — | 0 | 0 |
| Tuckerman Rehabilitation And Healthcare Center | 1.1 mi | — | 5 | 0 |
| Carriage Hill Bethesda | 2 mi | — | 4 | 0 |
| Hebrew Home Of Greater Washington | 2.1 mi | — | 5 | 0 |
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