Bethesda

In the surveyor’s words

From the most serious findings on record at Bethesda, in the surveyor’s own words.

• Actual harm, isolatedF684Nov 5, 2024

  Based on interview and document review, the facility failed to identify, monitor, and comprehensively assess for dehydration and significant weight loss for 1of 3 residents (R1) reviewed for change of condition. The facility's failures resulted in harm for R1 who had a 20 pound weight loss in 18 days and was subsequently admitted to the hospital for dehydration, acute renal failure, and later died . Findings include: R1's admission minimum data set (MDS) dated [DATE], indicated R1 had severe cognitive impairment and was dependent on staff for all activities of daily living (ADL)'s. […]

• No harm, potential for more than minimal, widespreadF851Jan 24, 2024

  Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 4), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: Payroll Based Journal (PBJ) [NAME] Report 1705 identified the following dates triggered: 9/2/23, 9/3/23, 9/4/23, 9/9/23, 9/10/23, 9/15/23, 9/16/23, 9/17/23, 9/23/23, 9/24/23 and 9/30/23 for failure to have licensed nurse coverage 24 hours per day. Daily staff schedules on the above-mentioned dates identified licensed nursing staff including registered nurses had worked and therefore the data submitted in the PBJ to CMS was inaccurate. […]

• No harm, potential for more than minimal, widespreadF921Jan 24, 2024

  Based on observation, interview and document review, the facility failed to provide a safe and sanitary environment. This had the potential to affect all 186 residents. During observations in the facility kitchen on 01/22/24 at 11:18 a.m., seven of fourteen exhaust hood filter panels were noted to have areas of one quarter to one-inch-thick grease imbedded with dust hanging over a double convection oven, a stationary kettle filled with water and no lid as well as a 2-burner natural gas stock pot range. […]

• No harm, potential for more than minimal, widespreadF880Dec 29, 2021

  Based on observation, interview and document review the facility failed to ensure staff were wearing appropriate eye protection while in resident care areas, and ensure visitors donned (to put on) the appropriate personal protective equipment (PPE) and informed of the risks of entering a resident room for 2 of 3 residents (R5 and R6) who was reviewed for Transmission Based Precautions (TBP) while visiting to prevent and minimize the spread of the COVID-19 virus. Findings include: On 12/28/21, at 2:45 p.m. nursing assistant (NA)-A was observed visiting with a resident on the memory care unit, wearing a surgical mask but no eye protection. Resident was not wearing a mask and NA-A was within 10 inches of resident's face visiting. On 12/28/21, at 2:48 p.m. […]

• No harm, potential for more than minimal, patternF812Dec 10, 2025

  Based on observation, interview and document review, the facility failed to store food in accordance with professional standards for food safety in 1 of 2 refrigerators on the 100-units. This had the potential to affect all 40 residents that resided on the unit.Findings include:On 12/9/25 at 4:49 p.m., the refrigerator on the 101-120 unit was reviewed with dietary aide (DA)-A. Contents of the refrigerator included a square, foam take-out container, labeled with a resident's name. However, the container was not labeled with a date. DA-A verified the box was not dated, but should have been dated, to ensure the resident did not eat spoiled food.On 12/9/25 at 4:55 p.m., the refrigerator on the 121-140 unit was reviewed with DA-B. […]