Bethesda Home

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF801Nov 2, 2023

  Based on observation, interview, and record review the facility failed to ensure there was sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services for 13 of 14 residents on a pureed diet (food blended to a smooth consistency similar to pudding, mashed potatoes, or applesauce). The failure to employ either a full-time dietician, or a certified dietary/food service manager resulted in inadequate oversight of kitchen staff and improper pureed diet food preparation and had the potential to result in inadequate nutrition for residents on pureed diets. See also tag F 805. Findings: During a concurrent observation and interview on 10/30/23, at 11:30 a.m., in the kitchen, Cook stated he was going to puree the meatloaf. […]

• No harm, potential for more than minimal, widespreadF805Nov 2, 2023

  Based on observation, interview, and record review the facility failed to follow the facility's recipes for 13 of 13 residents on pureed diets (pureed food is food blended to a smooth consistency similar to mashed potatoes, pudding, or applesauce). This failure resulted in unknown nutritional content of pureed meats, vegetables, and starches, and had the potential to result in inadequate nutritional intake for residents on pureed diets. See also tag F 801. Findings: During a concurrent observation and interview on 10/30/23, at 11:30 a.m., in the kitchen, Cook stated he was going to puree the meatloaf. Cook placed sliced cooked meatloaf in a blender, added hot, steaming, clear liquid, which he stated was water, and turned on the blender. […]

• No harm, potential for more than minimal, widespreadF880Nov 2, 2023

  Based on interview and record review, for 37 of 37 residents, the facility failed to have measures in place for facility water systems to prevent the growth of Legionella (a bacteria spread through contaminated water which can lead to severe lung inflammation) and other water-borne pathogens (a virus, bacteria, or other organism that causes an illness). This failure had the potential to expose facility residents to water-borne pathogens, including Legionella, and result in illness and hospitalization . Findings: During an interview on 11/01/23 at 9:09 a.m., with Administrator (Admin), Admin stated he was not aware of any measures in place to test for Legionella in the facility's water systems and he would check with the maintenance department. […]

• No harm, potential for more than minimal, widespreadF583Oct 21, 2022

  Based on observation, interview, and record review, Licensed Vocational Nurse 1 (LVN 1) failed to protect the privacy of all 38 residents in the facility when the list of resident names with vital signs (clinical measurements that indicate the status of a person's essential body functions) was left unattended on top of the medication cart. This failure had the potential to result in unauthorized access to information pertaining to residents' medical condition. Findings: During a medication administration observation and concurrent interview on 10/19/22, at 7:30 a.m., LVN 1 entered the first resident room in the hallway and left the facility form containing the list of all the resident names with vital signs, facing up on top of the unattended medication cart. […]

• No harm, potential for more than minimal, widespreadF801Oct 21, 2022

  Based on observation, interview, and facility document review the facility failed to: 1. Ensure the Registered Dietitian (RD) provided frequent consultation to Food and Nutrition Services Director; and 2. Employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. These failures resulted in inadequate oversight of kitchen staff to ensure staff were conducting job duties in a safe and sanitary manner, resulting in the potential for food borne illness for 38 residents who ate food from the kitchen out of a facility census of 38. […]