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, patternF552Apr 15, 2026

  Based on record review, interview, and policy review, the provider failed to ensure the staff educated the resident or the resident's representative of the risks versus benefits of medications or of alternative treatments to make an informed decision for the consent for the use of psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) before they were administered to three of three sampled residents (1, 12, and 25). Findings include:1. Review of resident 1's electronic medical record (EMR) revealed that he was admitted to the facility on [DATE]. His 2/11/26 Brief Interview Status (BIMS) assessment score was 10, which indicated his cognition was moderately impaired. […]

• No harm, potential for more than minimal, patternF583Jan 9, 2025

  Based on observation, interview, document review, and policy review the provider failed to ensure practices were in place to ensure the residents' right to privacy for six of six (1, 12, 20, 25, 37, and 42) sampled residents with audio and video monitoring devices in their rooms. *Obtain consent for audio and video monitoring use for six of six (1, 12, 20, 25, 37, and 42) sampled residents with audio and video monitoring devices in their rooms. Findings include: 1. Observation on 1/7/25 at 2:18 p.m. […]

• No harm, potential for more than minimal, patternF585Jan 9, 2025

  Based on interview, observation, record review, and policy review, the provider failed to implement an effective grievance process to ensure two of two sampled residents (10 and 32) who had reported grievances included documentation, investigation, and follow-up with the resident regarding issues of resident care and quality of life that were important to the resident. Specifically, the provider failed to ensure the following: *All written grievance decisions included the date that the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken… […]

• No harm, potential for more than minimal, patternF684Jan 9, 2025

  Based on interview, record review, and policy review, the provider failed to maintain the physical, mental, and psychosocial wellbeing by ensuring staff promptly respond to call lights for five of five residents (2, 10, 17, 32, and 35) who used call lights to alert staff of their assistance needs. Findings include: 1. Interview on 1/7/25 at 9:03 a.m. with resident 35 revealed: *She stated she had to wait too long for her call light to be answered. -It took up to 45 minutes for the call light to be answered, usually it was one-half hour, and seldom was it 15 minutes or less. -The wait time was especially worse in the mornings. *She needed help to get dressed and undressed. -She did not need assistance to use the bathroom. 2. Interview on 1/7/25 at 9:09 a.m. […]

• No harm, potential for more than minimal, patternF812Sep 13, 2023

  Based on observation, interview, and policy review, the provider failed to ensure proper glove use and hand hygiene were performed during two of three meal services by two of three observed dietary cooks (D and E) in the dining room. Findings include: 1. Observation on 9/12/23 from 7:54 a.m. through 8:28 a.m. with cook D revealed she: *Was wearing gloves while serving breakfast from the steam table in the dining room. *Took a resident's menu card from the card rack on the steam table and placed it next to a plate. […]