Montcare at Bethesda

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF584Feb 25, 2026

  Based on observations and interviews, the facility failed to ensure a homelike environment was provided for all residents. This was evident to be true for 9 out of 44 resident rooms observed during an annual recertification survey. The findings include: During observational rounds and interview with staff #22 on 02/18/2026 at 7:45 AM the following observations were made: room [ROOM NUMBER]-bathroom sink hot water facet dial was broken off and missing with water running continuously.room [ROOM NUMBER]-bathroom wallpaper was torn, no towel rack, lightbulbs in light fixture were not working, and bathroom cove base was noted to be missing and or not in good repair.room [ROOM NUMBER]-bathroom had a brown color, resembling rust, substance found around the base of the toilet seal as well as on… […]

• No harm, potential for more than minimal, patternF623Nov 6, 2024

  Based on record review and interview it was determined that the facility failed to 1) notify the Ombudsman of a Resident's (Resident #23) transfer to an acute care facility and 2) notify the Resident (Resident #47) /Resident representative of transfer to an acute care facility in writing. This was found to be evident for 2 (Resident #23 & #47) out of 3 residents reviewed for transfers during the annual survey. The findings include: 1) During a review of Resident #23's medical record conducted on 11/01/2024 at 10:03 AM it was revealed that the resident was transferred to a Hospital emergency roiagnom on [DATE]. A review of the Ombudsman notification of transfers was conducted on 11/04/24 at approximately 9:00 AM. […]

• No harm, potential for more than minimal, patternF625Nov 6, 2024

  Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 1 (#47) out of 3 residents reviewed for hospitalization s during the annual survey. The findings include: On 11/04/24 at 10:13 AM, a review of Resident #47's clinical record revealed that Resident #47 was transferred to the hospital for further evaluation of his/her medical needs on the following dates: 4/12/24 and 5/5/24. […]

• No harm, potential for more than minimal, patternF761Nov 6, 2024

  Based on observations and staff interviews it was determined that the facility failed to 1) maintain a safe and effective system for securing medication and 2) store medications properly. This was found to be evident for 1 out of 3 medication carts observed during the re-certification survey. The findings include: 1) During an interview conducted on 10/31/24 at 1:12 pm, Resident #85 gave this surveyor a set of keys on a lanyard that he/she stated were found on the hallway floor of the 1st floor nursing unit on the evening of 10/30/24. The Resident further stated that the keys belonged to the medication cart. An interview was conducted on 10/31/24 at 1:15 PM with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). […]

• No harm, potential for more than minimal, patternF812Nov 6, 2024

  Based on observations and staff interviews, it was determined that the kitchen failed to store food items to maintain the integrity of the specific item. This was evident during multiple observations of the kitchen on a recertification survey. The findings include: On 10/28/24 at 9:32 AM surveyors conducted an initial tour of the kitchen. During the tour, surveyors identified 2 items within the food prep refrigerator that were improperly stored: - A bottle of Red Cooking Wine marked with an open date showing 8/15/24 and a dispose date of 9/15/24 - An opened 48 oz glass container of Concord Grape Jelly without any open date and dispose date. […]