5721 Grosvenor Lane, Bethesda, MD 20814 · Montgomery County · (301) 530-1600
200 certified beds, about 180 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1989
CMS Care Compare ratings, data as of September 1, 2026 · CCN 215187 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on April 27, 2026, inspectors cited 14 health deficiencies (the Maryland average is 17, the national average 9.2).
None of its 37 health citations since January 2020 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.08 hours per resident per day, against 3.87 across Maryland and 3.86 nationally. Registered nurses accounted for 0.49 of those hours.
47.9% of nursing staff left within the year CMS measured (Maryland average 40.2%).
CMS links it to Sterling Care, an affiliated group of 6 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 37 health citations on file.
Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to accommodate a dependent resident's needs by not ensuring the resident's motorized wheelchair was in working condition. This was evident for 1(Resident #156) of 1 resident reviewed for reasonable accommodation of needs during the annual survey.
Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that the Responsible Party (RP) and/or legal guardian was notified of changes in a resident's condition. This was evident for 2 of 3 changes of conditions reviewed for (Resident #6).
Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure a safe, clean, comfortable and homelike environment. This was evident for 2 (Chesapeake and Gateway) out of 5 units, rooms (240 and 252) and 1 of 1 driveway observed during the annual survey.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to document the reason for hospital transfer and discharge. This deficient practice was evident for two (Resident #195, Resident #197) residents reviewed for inappropriate discharge during the annual survey.
Inspectors wroteBased on record reviews, and interviews, it was determined that the facility failed to provide the resident's responsible party (RP) with a written bed hold notice upon hospital transfer. This deficient practice was evident for one ( Resident #195) of two residents reviewed for discharge process during the annual survey.
Inspectors wroteBased on record review, and interviews, it was determined that the facility failed to accurately document a Minimum Data Set (MDS) assessment in a Resident's medical record. This was found evident of 2 (Resident #23 & #6) of 51 residents reviewed in the survey.
Inspectors wroteBased on record reviews, and interviews, it was determined that facility staff failed to ensure a resident's responsible party (RP) received a written summary of the resident's baseline care plan. This deficient practice was evident for one resident (Resident #123 ) reviewed for baseline care plans during the annual survey.
Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive care plan to meet the needs of a Resident. This was evident for 1 (Resident #6) out of 1 resident reviewed for hospice care during the survey.
Inspectors wroteBased on clinical record review and interviews, it was determined that the facility failed to hold care plan meetings with the interdisciplinary team for a resident at the time of the quarterly and annual revision of their care plans, and also failed to invite the resident/responsible party to these meetings. This was evident for 1 (Resident #114) of 8 residents reviewed for care planning during the survey.
Inspectors wroteBased on interviews and record reviews, it was determined the facility failed to ensure a resident who required assistance with activities of daily living (ADLs) received scheduled showers. This deficient practice was evident for one resident (#133) reviewed for ADL care during the annual survey.
Inspectors wroteBased on observation, medical record review, and interviews, it was determined that the facility staff failed to provide appropriate care measures to prevent complications from a hand contracture. This was evident for 1 (Resident #7) of 2 residents reviewed for mobility.
Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to follow professional standards of practice when administering intermittent intravenous (IV) antibiotic infusions. This was found to be evident in 1 (#200) out of 1 resident observed for intravenous access care.
Inspectors wroteBased on record review and interviews, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards for accuracy. This was found evident in 4 (Resident #138, #6, #4, & #8) of 51 residents reviewed during the survey.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to handle soiled linen safely. This was found to be evident in 1 (Rosemary) out of 5 units observed during the annual survey.
Inspectors wroteBased on observations and interviews, the facility failed to provide 3 (R24, R25, and R26) of the 3 sampled residents' meals at the designated normal mealtimes and in accordance with their needs, preferences, and requests. The facility census was 174. Record review of the facility's dietary policy, last revised 10/2022 and titled Frequency of Meals, documented that at least three daily meals will be provided, at regular times comparable to normal mealtimes in the community. The policy described the procedures as follows:Dietary Procedures:The Dining Service Director coordinates with the residents, Administrator, and/or Director of Nursing Services to establish the meal and snack times that are comparable with normal times in the community. A schedule of meal service times will be provided to the nursing staff and available in resident/patient care areas. [...]
Inspectors wroteBased on observations, records reviews and staff interviews, the facility failed to provide a functional, sanitary and comfortable environment for 5(R#3, R#20, R#21, R#22 and R#23) of 5 sampled residents when a toilet had rust and black mold around the seal of toilet along with leakage with water. The facility census was 174.
Inspectors wroteBased on observations, staff and resident interviews, and record reviews, it was determined that the facility failed to treat a resident with dignity by not: 1) ensuring that Resident #429's foley drainage bag was covered; and 2) promoting an environment that enhances the quality of life. This was evident for 2 (Resident #429 and Resident #97) of 17 residents reviewed during the survey.
Inspectors wroteBased on resident record reviews and staff interviews, it was determined that the facility failed to provide residents and/or the resident's representative with an opportunity to formulate an advanced directive. This was evident for 3 (Residents #169, #85, and #173) out of 9 residents reviewed during the survey.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide a clean, safe, homelike environment. This was evident for 8 (Residents #51, #85, #94, #154, #90, #478, #109, and #117) out of 183 residents observed during the survey.
Inspectors wroteBased on resident family interviews and facility record reviews, it was determined that the facility failed to prevent residents from being physically abused. This was evident for 1 (Residents #85) out of 20 residents reviewed during the survey.
Inspectors wroteBased on observation and record review, it was determined that the facility nursing staff failed to follow professional standards of practice when administering medications to (resident #110 and #30). This was evident during observation of medication administration.
Inspectors wroteBased on resident and staff interviews, medical and administrative record reviews, and observations it was determined that the facility failed to address a resident's request for removal of a feeding tube. This was evident for 1 (#142) out of 4 residents reviewed for nutrition during the survey.
Inspectors wroteBased on observations, medical record review, and interviews, it was determined that the facility staff failed to maintain a medication error rate of less than 5 percent. This was evident for 6 out of 29 opportunities observed for medication errors. The findings Include: 1) During medication observation on 3/4/25 at 8:05 AM for Resident #61, the surveyor observed LPN (Nurse Practical Nurse) Nurse#21 preparing the resident's insulin injection. Nurse #21 filled an empty insulin syringe with 30 units of insulin injection from a prefilled insulin pen. Nurse #21 went into Resident #61's room to give him/her the insulin injection. The surveyor questioned the nurse about how many units of insulin were to be given to the resident per the attending provider's order, and she reported 24 units of insulin. [...]
Inspectors wroteBased on observation, interview with facility staff and medical record review, it was determined that the facility staff failed for a significant medication error for an Insulin Dependent resident. This was evident during the review of 1 of 1 resident (Resident #61) reviewed during survey process. The Findings Include: During medication administration on 3/4/25 at 8:05 AM for Resident #61, the surveyor observed nurse #21 preparing the resident's insulin injection. Nurse#21 filled an empty insulin syringe with 30 units of insulin injection from a prefilled insulin pen. Nurse #21 went into Resident #61's room to give him/her the insulin injection. The surveyor questioned the nurse about how many units of insulin were to be given to the resident per the attending provider's order, and she reported 24 units of insulin. [...]
Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to properly store medications, as evidenced by failing to discard expired medications. This was evident for 1 of 3 medication storage rooms observed during the survey.
Inspectors wroteBased on observations and resident and staff interview, it was determined that the facility failed to provide food and drink that accommodates the resident intolerances. This was found to be evident for 1 of 1 resident (Resident #100) selected for review.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to provide a sanitary, comfortable environment for residents, staff and public. This was evident for 1 unit out of 5 units observed during the survey.
Inspectors wroteBased on surveyor observation and staff interviews, it was determined that the facility failed to store, prepare, distribute, and serve food using sanitary practices in accordance with professional standards for food services safety. This was evident in the main kitchen and the second floor dining room.
Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility staff failed to invite residents and/or their representative for interdisciplinary care conferences, and failed to review and revise residents' care plan as necessary. The finding was evident for 5 of 38 residents selected for review during the survey (#45, #78, #153, #104, #14, #37, and #137).
Inspectors wroteBased on resident interview, surveyor observation, review of the clinical record and interview of facility staff, it was determined that the facility staff failed to provide timely intervention for a resident with dental problems. This finding was evident in 1 of 3 residents reviewed for the dental care area (Resident #32).
Inspectors wroteBased on the review of administrative documents and interviews with residents and facility staff, it was determined that the facility failed to ensure that residents who filed written grievances were informed of the findings and corrective actions taken. This finding was evident for 1 of 1 residents (Resident #56) reviewed for the personal property care area.
Inspectors wroteBased on observations, a review of clinical records, and interviews with family members and facility staff, it was determined that the facility staff failed to follow a physician's order for 1 of 38 residents reviewed during the survey (Resident #14).
Inspectors wroteBased on surveyor observation, review of the clinical record, and staff interview, it was determined that that the facility staff failed to utilize appropriate measures to prevent complication related to an indwelling catheter for 1 of 3 residents reviewed for the indwelling catheter care area (Resident #12).
Inspectors wroteBased on surveyor observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that medication administration error were less than five (5) percent. This finding was evident for 3 of 25 (12%) medication administration opportunities observed during the survey.
Inspectors wroteBased on surveyor observations and interviews with facility staff, it was determined that the facility staff failed to ensure residents safely disposed of smoking cigarettes. This finding was evident during 1 of 4 smoking observations.
Inspectors wroteBased on the review of the clinical record, interviews with legal guardians and facility staff, it was determined that the facility failed to notify a legal guardian of changes in a residents' condition. This finding was evident for 1 of 38 residents reviewed during the survey (Resident #139).
Inspectors wroteBased on the review of a clinical record, interviews with legal guardians and facility staff, it was determined that the facility failed to report an incident of injury of unknown origin to the Office of Health Care Quality (OHCQ). This finding was evident for 1 of 38 residents reviewed during the survey (Resident #139).
17 fire safety citations on file: 8 on April 27, 2026, 7 on March 6, 2025, 2 on January 31, 2020.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Maryland | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.08 | 3.87 | 3.86 |
| Registered nurses | 0.49 | 0.84 | 0.69 |
| All nursing staff on weekends | 2.71 | 3.47 | 3.42 |
| Nurse aides | 1.69 | ||
| Licensed practical nurses | 0.91 | ||
| Nursing staff turnover (share who left in a year) | 47.9% | 40.2% | 45.8% |
| Registered nurse turnover | 23.8% | 38.7% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.84 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.23 on weekdays and 2.71 on weekends, 16% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.08 in April to June 2025 to 3.08 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.08 | 0.49 | 3.23 | 2.71 | 0.0% | 0 of 90 | 180 |
| Oct to Dec 2025 | 3.17 | 0.45 | 3.29 | 2.87 | 0.0% | 0 of 92 | 172 |
| Jul to Sep 2025 | 3.30 | 0.44 | 3.49 | 2.81 | 0.0% | 0 of 92 | 169 |
| Apr to Jun 2025 | 3.08 | 0.42 | 3.24 | 2.68 | 0.0% | 0 of 91 | 178 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Maryland, Jan to Mar 2026 | 3.73 | 0.74 | 3.88 | 3.34 | 8.0% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Maryland, all employers | |||
| CNAs (nursing assistants) | $20.79 | $18.46 to $22.00 | 27,720 |
| LPNs and LVNs | $35.89 | $31.40 to $38.30 | 9,560 |
| Registered nurses | $47.98 | $40.26 to $51.61 | 52,910 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Maryland | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 10.2 | 20.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.1 | 0.5 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.5 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.3 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.7 | 1.1 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 8.9 | 22.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.1 | 5.9 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 8.0 | 13.8 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 25.3 | 21.0 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 11.9 | 9.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.4 | 1.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.9 | 1.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Sterling Care Bethesda's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (41.8% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
41.8% this home
No different from the national rate
US median of homes 51.5% · Maryland: 90 better, 29 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 109 eligible stays.
11.5% this home
No different from the national rate
US median of homes 10.7% · Maryland: 0 better, 41 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 109 eligible stays.
6.7% this home
No different from the national rate
US median of homes 7.1% · Maryland: 5 better, 6 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 67 eligible stays.
49.4% this home
Median of homes: Maryland61.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 87 residents counted.
0.0% this home
Median of homes: Maryland0.4% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 162 residents counted.
0.5% this home
Median of homes: Maryland2.4% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 162 residents counted.
96.9% this home
Median of homes: Maryland98.1% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 32 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: BETHESDA SNF OPERATOR LLC. CMS links this home to Sterling Care, a group of 6 nursing homes averaging 4.3 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Bbf Holdings LLC | 5% or greater direct ownership interest | Organization | 100% | 06/01/2022 |
| Jek Irrv Tr | 5% or greater indirect ownership interest | Organization | 06/01/2022 | |
| Nmj Irrv Tr | 5% or greater indirect ownership interest | Organization | 06/01/2022 | |
| Sava Acquisition LLC | 5% or greater indirect ownership interest | Organization | 06/01/2022 | |
| Frankel, Chaim | 5% or greater indirect ownership interest | Individual | 06/01/2022 | |
| Kagan, Jeffrey | W-2 managing employee | Individual | 06/01/2022 | |
| Kagan, Jeffrey | Corporate officer | Individual | 06/01/2022 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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