Bethesda Home

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 21, 2022

  The facility reported a census of 29 residents, including three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1 remained free from accident hazards, when on 04/23/22, Certified Nurse Aide (CNA) M failed to safely secure R1 in a whirlpool chair with the safety belt or safety bar, and failed to lower the resident's whirlpool chair to the lowest position before the CNA retrieved the resident's wheelchair, which was approximately two feet from the whirlpool chair, to transfer R1. CNA M left the resident suspended with the resident's feet dangling in the air and with no safety belt to secure him in the whirlpool chair while she went to retrieve the wheelchair. […]

• No harm, potential for more than minimal, widespreadF880Dec 14, 2021

  The facility reported a census of 27 residents. Based on observation, interview, and record review, the facility failed to ensure staff provided environmental cleaning in a sanitary manner to prevent the spread of infection, failed to ensure pet vaccinations remained up to date for resident's cat, failed to ensure the water temperature in the laundry remained at least 160 degrees Fahrenheit to ensure sanitary laundering of resident linen. Findings included: - Observation, on 12/08/21 at 08:28 AM, revealed housekeeping staff VV and WW changing resident bed linen. […]

• No harm, potential for more than minimal, widespreadF881Dec 14, 2021

  The facility reported a census of 27 residents. Based on interview and record review, the facility failed to ensure nursing staff followed the principles of antibiotic stewardship proactively to ensure antibiotic use in a safe and effective manner to prevent unnecessary side effects of antibiotics and development of antibiotic resistance in the residents of the facility. Findings included: - Review of the Antibiotic Stewardship Log, revealed the facility lacked the use of an assessment tool (for antibiotic appropriateness) at the initiation of antibiotic therapy. The facility reviewed antibiotic appropriateness at the completion of the antibiotic. […]

• No harm, potential for more than minimal, patternF880Mar 12, 2025

  The facility had a census of 27 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to adhere to infection control for enhanced barrier precautions (EBP - an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities) for Resident (R) 2 who had a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This placed the resident at risk for possible exposure of infection. […]

• No harm, potential for more than minimal, isolatedF684Jun 23, 2025

  The facility reported a census of 28. The sample included three residents. Based on interview and record review the facility failed to follow physicians' orders for the care of a surgical wound for Resident (R)1. This placed R1 at risk for wound complications and infection. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of a fracture (a broken bone) of the right lower leg and a fracture of the right shoulder R1's admission Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 10 indicating moderately impaired cognition. R1 required staff assistance with dressing, grooming, toileting, and showering. The MDS noted R1 had a surgical wound. […]