Carriage Hill Bethesda
CARRIAGE HILL BETHESDA in BETHESDA, MD — inspection on March 26, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
his or her rights.
his/her own decisions, including the right to participate in and direct his/her personal and financial
consent prior to submitting a Medicaid application and inaccurately represented the resident's decision-making capacity.
This deficient practice was identified for 1 of 1 resident (Resident #69) reviewed for resident rights.Findings include:
During an interview conducted on 3/24/25 at approximately 11:00 AM with Resident #69 and the resident's daughter regarding complaint #2719381, Resident #69 stated that he/she had previously informed the social worker that he/she did not want to apply for Medicaid and planned to return home.
The resident and the resident's daughter further stated that the facility submitted a Medicaid application without the resident's knowledge or consent. Resident #69 stated, I don't know how they could do that without my information and my permission.
During an interview with the Administrator (Staff #1) on 3/24/25 at approximately 1:00 PM, the Administrator confirmed that a Medicaid application had been submitted on behalf of the resident, stating it was done to help him/her.
During an interview with the Business Office Manager (Staff #13) on 3/25/25 at approximately 1:30 PM, she stated she had been advised by the facility that it was acceptable to submit the Medicaid application on the resident's behalf.Upon request, the surveyor reviewed the Medicaid application submitted for Resident #69.
Review revealed the application was completed under the designation applicant without representative who lacks capacity to appoint a representative.
However, review of the resident's medical record revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact and capable of making his/her own decisions.These findings demonstrate the facility failed to honor the resident's right to make informed decisions and to refuse services and failed to accurately represent the resident's decision-making capacity.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
215234 03/26/2026
Carriage Hill Bethesda 5215 Cedar Lane Bethesda, MD 20814
During an interview on 03/19/2026 at 12:30 PM staff #2 stated, (The resident) Does not have epilepsy or seizures and there is nothing in the medical file that states he/she ever had a history of epilepsy or seizures.
Staff #2 also stated, I will let the doctor know so this can be corrected.
Staff #2 was unable to explain how the facility or pharmacy verified that the correct indication/reason was used for Resident #50's medication orders.
215234 03/26/2026
Carriage Hill Bethesda 5215 Cedar Lane Bethesda, MD 20814
Review of March 2026 Medication Administration Record revealed Resident #50 received the 3 times a day Acetaminophen and received as needed Acetaminophen totaling 4000 mg which exceeds 3g (3000 mg) on 03/05 and 03/17.
During an interview on 03/23/2026 at 10:00 AM with staff #2, Resident #50's March 2026 Medication Administration Records were reviewed with surveyor.
Staff #2 agreed that Resident #50 received over 3g of Acetaminophen on 03/05, 03/17 and would contact the doctor to have medication order corrected. 2.Review of Resident #50's medical record on 03/23/2026 at 9:20 AM revealed that on 09/11/2025 the physician ordered Oxycodone HCL Oral Tablet 5 MG (Oxycodone HCL) Give 1 tablet by mouth every 6 hours as needed for mild to moderate pain, and Oxycodone HCL Oral Tablet 7.5 MG (Oxycodone HCL) Give 7.5 mg by mouth every 6 hours as needed for severe pain rated 7 to 10.
Review of March 2026 Medication Administration Records revealed on 03/18/26 Resident #50 received Oxycodone 5mg 1 tablet by mouth at 07:47 AM for pain level 5, and Oxycodone 7.5mg 1 tab by mouth at 09:37 AM for pain level 4.
During an interview on 03/23/2026 at 10:05 AM with staff #2, Resident #50's March 2026 Medication Administration Records were reviewed with surveyor.
Staff #2 agreed and verified that resident #50 was given an additional dose of Oxycodone 7.5 mg in error because it was before the 6-hour time frame. 3.Review of Resident #50's medical record on 03/23/2026 at 9:25 AM revealed that on 09/11/2025 the physician ordered Oxycodone HCL Oral Tablet 7.5 MG (Oxycodone HCL) Give 7.5 mg by mouth every 6 hours as needed for severe pain rated 7 to 10.
Review of March 2026 Medication Administration Records revealed Resident #50 received Oxycodone 7.5mg 1 tab by mouth on 03/01, 03/02, 03/10, 03/15, 03/18 for a pain level of 4, on 03/14 for a pain level of 6 and on 03/18 for a pain level of 3.
During an interview on 03/23/2026 at 10:15 AM with staff #2, Resident #50's March 2026 Medication Administration Records were reviewed with surveyor.
Staff #2 agreed and verified that resident #50 was given Oxycodone HCL Oral Tablet 7.5 MG for resident pain levels that were not severe rated 7 to 10 per physician orders and was given in error.
215234 03/26/2026
Carriage Hill Bethesda 5215 Cedar Lane Bethesda, MD 20814
The surveyor asked both staff (#34, #35) how Resident #109 is able communicate with family privately, and they both stated that sometimes, Resident #109 will use the roommate's phone.
The Nurse stated that she would contact maintenance regarding the phone line for Resident #109.On the same date at approximately 11:15 AM, the Administrator asked if this surveyor would accompany him to Resident #109's room.
Upon entering the resident room, the Maintenance Director (MD) staff #5 was present and pointed out that there is only one phone jack in the room.
The Administrator went on to explain that there are multiple rooms in the facility that have only one phone jack. He went on to explain that before acquiring the building, the rooms were considered private. He stated that the facility is currently working on resolving this.
The Administrator stated that the charge nurse carries a phone that the resident can use in the interim but confirmed that the resident does not have access to a phone.Another observation was made at that time with the Administrator and the MD, of the resident TV remote control.
The MD was asked if the resident remote control worked? The MD tried multiple times to get the television to come on using the remote control and it did not turn on.
The MD manually turned the TV on.
The Administrator instructed the MD to change the batteries in the TV remote control.
The MD verbally agreed.