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 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 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 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.
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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) |
|---|---|---|---|---|
| Tuckerman Rehabilitation And Healthcare Center | 0.5 mi | — | 5 | 0 |
| Maplewood Park Place | 0.7 mi | — | 0 | 0 |
| Montcare At Bethesda | 1 mi | — | 4 | 0 |
| Carriage Hill Bethesda | 1.3 mi | — | 4 | 0 |
| Hebrew Home Of Greater Washington | 2.1 mi | — | 5 | 0 |
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