11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Bethesda, MD
4-star overall rating with 4-star inspections with 11 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
5721 Grosvenor Lane, Bethesda, MD
(301) 530-1600
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
200
Certified beds
Average residents
169
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sterling Care
Operator or chain grouping
Approved since
1989-02-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 4 health / 2 staffing / 5 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
RN hours / resident day
0.44
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.30
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
2.81
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
9,194
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.79
Baseline 17.94% · Performance 20.60% · Measure score 1.79 · Achievement 1.79 · Improvement 0
Healthcare-associated infections
3.83
Baseline 5.91% · Performance 6.69% · Measure score 3.83 · Achievement 3.83 · Improvement 0
Total nurse turnover
3.35
Baseline 54.29% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0.96
Adjusted total nurse staffing
0.84
Baseline 3.92 hours · Performance 3.32 hours · Measure score 0.84 · Achievement 0.84 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.49% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 109 · Observed rate 12.84% · Lower 95% interval 8.07% |
| Discharge to community | 41.84% |
50.57%
8.7 pts worse
|
No Different than the National Rate · Eligible stays 109 · Observed rate 33.94% · Lower 95% interval 33.52% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.15% |
95.27%
0.9 pts better
|
Numerator 125 · Denominator 130 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 130 |
| Discharge self-care score | 34.21% |
53.69%
19.5 pts worse
|
Numerator 26 · Denominator 76 |
| Discharge mobility score | 36.84% |
50.94%
14.1 pts worse
|
Numerator 28 · Denominator 76 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 129 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.69% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 7.46% · Lower 95% interval 4.36% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 165 |
| Staff flu vaccination coverage | 57.38% |
42%
15.4 pts better
|
Numerator 105 · Denominator 183 |
| Discharge function score | 47.37% |
56.45%
9.1 pts worse
|
Numerator 36 · Denominator 76 |
| Transfer of health information to provider | 94.29% |
95.95%
1.7 pts worse
|
Numerator 66 · Denominator 70 |
| Transfer of health information to patient | 96% |
96.28%
0.3 pts worse
|
Numerator 24 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 17.39% |
25.2%
7.8 pts worse
|
Numerator 16 · Denominator 92 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.3
0.7 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.5 · Expected 2.4 · 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 0.9 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.9% |
91.9%
4 pts worse
|
93.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.2% · Q2 89.9% · Q3 87.2% · Q4 80.1% · 4Q avg 87.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.4% |
96.6%
2.8 pts better
|
95.5%
3.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
2.3%
0.7 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.9% · Q3 1.3% · Q4 0.7% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 22.9% |
21.4%
1.5 pts worse
|
11.4%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 33.1% · Q3 18.5% · Q4 12.0% · 4Q avg 22.9% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
5.7%
About the same
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.8% · Q3 4.0% · Q4 6.8% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.0% |
16.1%
9.1 pts better
|
19.6%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 5.1% · Q3 7.9% · Q4 6.0% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.7% |
15.3%
6.6 pts better
|
16.7%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 8.9% · Q3 7.4% · Q4 9.0% · 4Q avg 8.7% · 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 | 6.4% |
26.6%
20.2 pts better
|
16.3%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 3.8% · Q3 5.8% · Q4 9.3% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.7% |
22.9%
9.2 pts better
|
14.9%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 15.7% · Q3 6.5% · Q4 11.0% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
0.7%
0.6 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.5% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.5%
1.5 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 30.3% |
25.4%
4.9 pts worse
|
19.8%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.1% · Q2 25.1% · Q3 30.6% · Q4 35.8% · 4Q avg 30.3% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
6.3%
2.7 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.6% · Q3 3.5% · Q4 4.2% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 50.9% |
78.4%
27.5 pts worse
|
81.7%
30.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 78.0% · Q2 63.6% · Q3 37.1% · Q4 26.5% · 4Q avg 50.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.5% |
9.9%
0.6 pts worse
|
12.0%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 10.2% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 1.5% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 47.2% |
80.6%
33.4 pts worse
|
79.7%
32.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 47.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.6% |
21.2%
5.4 pts worse
|
23.9%
2.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.6% · Observed 28.3% · Expected 25.4% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (3 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Resident Assessment and Care Planning (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-25
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-04-25
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-04-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-25
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-25
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-25
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-05
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-02-05
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-05-15
Fire Safety
Meet other general requirements.
Corrected 2019-05-15
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 2019-05-15
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-05-15
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-05-15
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-05-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-05-15
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-05-15
Inspection history
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-01
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-04-01
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-04-01
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-01
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-01
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-04-01
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-01
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-01
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 2025-04-01
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-04-01
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-04-01
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-09-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-03-17
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 2020-03-17
Health
Provide or obtain dental services for each resident.
Corrected 2020-03-17
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2020-03-17
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-03-17
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 2020-03-17
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-03-17
Health
Have policies on smoking.
Corrected 2020-03-17
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2020-03-17
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2020-03-17
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-04-29
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 2019-04-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-04-29
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-04-29
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-04-29
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2019-04-29
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-04-29
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-04-29
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2019-04-29
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-04-29
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-04-29
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2019-04-29
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-04-29
Health
Dispose of garbage and refuse properly.
Corrected 2019-04-29
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
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