Cycle 1
Health 2025-01-17 · Fire 2025-01-17
17 health deficiencies
Top issue: Resident Assessment and Care Planning (7 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Bethesda, MD
Carriage Hill Bethesda
3-star overall rating with 3-star inspections with 17 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
5215 Cedar Lane, Bethesda, MD
(301) 897-5500
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
103
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vierra Communities
Operator or chain grouping
Approved since
1991-08-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
3 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.73
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
1.13
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.71
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.86
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.50
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,698
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.22
Composite VBP score used to determine payment impact.
Payment multiplier
1.0019
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.85
Baseline 20.52% · Performance 17.79% · Measure score 7.85 · Achievement 7.85 · Improvement 7.31
Healthcare-associated infections
0
Baseline 7.83% · Performance 8.00% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
9.27
Baseline 60.35% · Performance 25.81% · Measure score 9.27 · Achievement 9.27 · Improvement 9
Adjusted total nurse staffing
2.17
Baseline 3.29 hours · Performance 3.70 hours · Measure score 2.17 · Achievement 2.17 · Improvement 1.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.36% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 458 · Observed rate 7.42% · Lower 95% interval 7.3% |
| Discharge to community | 59.83% |
50.57%
9.3 pts better
|
Better than the National Rate · Eligible stays 496 · Observed rate 54.44% · Lower 95% interval 55.6% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.07% |
95.27%
3.8 pts better
|
Numerator 321 · Denominator 324 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 324 |
| Discharge self-care score | 48.61% |
53.69%
5.1 pts worse
|
Numerator 105 · Denominator 216 |
| Discharge mobility score | 51.85% |
50.94%
0.9 pts better
|
Numerator 112 · Denominator 216 |
| Pressure ulcers or injuries, new or worsened | 1.54% |
2.29%
0.8 pts better
|
Numerator 5 · Denominator 324 · Adjusted rate 1.33% |
| Healthcare-associated infections requiring hospitalization | 8% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 289 · Observed rate 8.3% · Lower 95% interval 5.46% |
| Staff COVID-19 vaccination coverage | 6.85% |
8.2%
1.3 pts worse
|
Numerator 10 · Denominator 146 |
| Staff flu vaccination coverage | 70.27% |
42%
28.3 pts better
|
Numerator 104 · Denominator 148 |
| Discharge function score | 52.78% |
56.45%
3.7 pts worse
|
Numerator 114 · Denominator 216 |
| Transfer of health information to provider | 98.46% |
95.95%
2.5 pts better
|
Numerator 128 · Denominator 130 |
| Transfer of health information to patient | 96.43% |
96.28%
0.2 pts better
|
Numerator 135 · Denominator 140 |
| Resident COVID-19 vaccinations up to date | 37.1% |
25.2%
11.9 pts better
|
Numerator 69 · Denominator 186 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.3
1 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.5 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.5% |
91.9%
5.4 pts worse
|
93.4%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.0% · Q2 84.6% · Q3 83.1% · Q4 84.1% · 4Q avg 86.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
96.6%
0.8 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
2.3%
1.2 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.5% · Q4 1.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 21.7% |
21.4%
0.3 pts worse
|
11.4%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 27.3% · Q3 13.8% · Q4 26.2% · 4Q avg 21.7% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
5.7%
1.6 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 6.9% · Q3 5.1% · Q4 1.5% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.5% |
16.1%
5.6 pts better
|
19.6%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 13.1% · Q3 6.5% · Q4 7.4% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.1% |
15.3%
0.8 pts worse
|
16.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 14.3% · Q3 17.0% · Q4 14.3% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 33.3% |
26.6%
6.7 pts worse
|
16.3%
17 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.4% · Q4 21.1% · 4Q avg 33.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 35.1% |
22.9%
12.2 pts worse
|
14.9%
20.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.7% · Q2 51.0% · Q3 38.0% · Q4 15.8% · 4Q avg 35.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.5%
0.4 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.2% · Q3 1.6% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.4% |
25.4%
4 pts worse
|
19.8%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.8% · Q2 35.4% · Q3 19.1% · Q4 27.7% · 4Q avg 29.4% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
6.3%
1.7 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 12.6% · Q3 8.1% · Q4 5.4% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 62.5% |
78.4%
15.9 pts worse
|
81.7%
19.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 65.8% · Q2 66.0% · Q3 64.1% · Q4 53.0% · 4Q avg 62.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
9.9%
1 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 9.1% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.2% |
80.6%
4.4 pts worse
|
79.7%
3.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.0% |
21.2%
2.8 pts worse
|
23.9%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 26.1% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-02-14 · Fire 2020-02-14
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-01-07 · Fire 2019-01-07
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-17
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-17
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-17
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-17
F · Potential for more than minimal harm
2025-01-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-17
E · Potential for more than minimal harm
2019-01-07
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-01-22
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-17
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-17
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-17
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-17
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-17
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-17
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-17
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-17
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-17
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-02-28
E · Potential for more than minimal harm
2020-02-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-03-15
D · Potential for more than minimal harm
2020-02-14
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2020-03-15
D · Potential for more than minimal harm
2020-02-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-03-15
D · Potential for more than minimal harm
2020-02-14
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2020-03-15
D · Potential for more than minimal harm
2020-02-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2020-03-15
D · Potential for more than minimal harm
2020-02-14
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2020-03-15
B · Minimal harm
2020-02-14
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2020-03-15
D · Potential for more than minimal harm
2019-01-07
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-01-31
D · Potential for more than minimal harm
2019-01-07
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2019-01-31
D · Potential for more than minimal harm
2019-01-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-01-31
D · Potential for more than minimal harm
2019-01-07
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2019-01-31
B · Minimal harm
2019-01-07
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-01-31
B · Minimal harm
2019-01-07
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-01-31
B · Minimal harm
2019-01-07
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-01-31
Penalties and ownership
What sits behind the stars
Ownership
Carriage Hill Opco Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Mbeboh, Julius
Operational/Managerial Control · Individual
Vierra Management LLC
Operational/Managerial Control · Organization
Vucich, Derek
5% Or Greater Direct Ownership Interest · Individual
Vucich, Derek
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Maplewood Park Place
Bethesda, MD
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Sterling Care Bethesda
Bethesda, MD
4-star overall rating with 4-star inspections with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Tuckerman Rehabilitation And Healthcare Center
North Bethesda, MD
5-star overall rating with 5-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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