Oaks at Bethesda the

In the surveyor’s words

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

• Actual harm, isolatedF689May 28, 2026

  Based on record review, interview, facility investigation review and policy review, the facility failed to ensure a resident was not left in the shower alone, resulting in a fall with fracture. This affected one (Resident #2) of four residents reviewed for falls. The facility census was 49. Actual harm occurred on 04/04/26 when Resident #2, who required supervision and touching assistance with showering and bathing, was assisted into the bathroom to shower. Certified Resident Care Assistant (CRCA) exited the shower room leaving Resident #2 to shower herself. Resident #2 suffered a fall which resulted in a comminuted, intra-articular distal radius fracture on the right arm. […]

• Actual harm, isolatedF686Jan 22, 2024

  Based on observation, record review, resident and staff interviews, review of skin assessments, and facility policy review, the facility failed to prevent, comprehensively assess and timely treat a pressure ulcer and failed to prevent the pressure ulcer from worsening for Resident #298. This affected one resident (#298) of three residents reviewed for skin impairments. The facility census was 51. Actual Harm occurred on 01/05/24 when a new, facility-acquired, skin area was identified on Resident #298's left heel that developed within 30 days of the resident's admission. The area was assessed as a purple-black bruise without swelling and measured 3.5 centimeters (cm) long by 2.5 cm wide. […]

• Actual harm, isolatedF692Jan 22, 2024

  Based on observation, record review, resident and staff interviews, and facility policy review, the facility failed to timely address or implement effective nutritional interventions for Resident #298 who experienced a significant weight loss. This affected one resident (#298) of three residents reviewed for nutrition. The facility census was 51. Actual Harm occurred on 01/05/24 when Resident #298's weight revealed a significant weight loss of 5% in less than 30 days. The Registered Dietitian (RD) was not notified and did not address the significant weight loss until 01/10/24 (five days later) to make nutritional recommendations. […]

• No harm, potential for more than minimal, widespreadF880Jan 9, 2025

  Based on review of the infection control logs, review Center of Disease Control and Prevention (CDC) guidelines, observation, interview, and policy review, the facility failed to ensure policy and procedures were in place for laundering isolation linens and clothing and failed to ensure staff were knowledgeable on the process to prevent infection transmission throughout the facility. This had the potential to affect all 52 resident residing in the facility. Findings include: Review of the infection control log dated 11/2024 to 01/09/24 revealed in November 2024 there were three cases of Clostridium difficile (C-diff, a highly contagious bacterium that causes diarrhea and colitis). […]

• No harm, potential for more than minimal, widespreadF812Jan 22, 2024

  Based on observation, staff interview, and record review, the facility failed to properly store and date foods, dispose of expired foods, and complete proper hand hygiene during lunch meal service. This had the potential to affect 51 residents who received meals from the kitchen. The census was 51. Findings include: 1. The following concerns were noted during the main initial kitchen tour conducted on [DATE] between 9:38 A.M. and 10:07 A.M. Observation of the main fridge revealed 12 undated containers of moldy strawberries, 13 undated containers of moldy blackberries, an undated opened bag of fresh carrots and an opened large package of cream cheese with a use by date of [DATE]. […]