Bethesda Home

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Staffing

No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

20 citations, most serious first. The 10 most serious are shown; the remaining 10 are one tap away and print in full.

• Potential for harm · E2024-10-25 · tag F0727 — failed to provide required RN coverage — pattern
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to schedule a registered nurse (RN) for eight consecutive hours a day, seven days a week, for 86 days in 2024. This failure had the potential to place residents at risk to receive insufficient care. Findings: During an interview on 10/23/24 at 1:32 p.m. with Minimum Data Set Coordinator (MDSC), MDSC stated there were multiple days when the facility did not have a RN on duty for eight hours a day. During an interview on 10/23/24 at 1:50 p.m. with Director of Staffing Development (DSD), DSD stated it was important to have an RN on duty for emergency assessments, initial resident assessments, IV medications (intravenous medications - a method of administering fluids or substances into a vein using a needle or tube) and for medication destruction. During a concurrent interview and record review on 10/24/24 at 10:31 a.m. with Administrator (ADM), PBJ (Payroll-Based Journal) Staffing Data Report [NAME] Report 1705D FY (Fiscal Year) Quarter 2 2024 (a method staffing data from nursing facilities), dated 10/15/24 and PBJ Staffing Data…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-10-25 · tag F0730 — pattern
  Observe each nurse aide's job performance and give regular training.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to ensure four out of four Certified Nursing Assistants (CNAs) and one out of one Certified Nursing Assistant Lead (CNAL) had the appropriate competencies to care for residents when the facility did not complete Annual Performance Evaluations for CNAs 1, 2, 3 and 4 and CNAL. This failure had the potential for resident care to be provided in an unsafe and incompetent manner. Findings: During an interview on 10/23/24 at 2:10 p.m. with CNA 1, CNA 1 stated they did not have an Annual Performance Evaluation in the last year. During a concurrent interview and record review on 10/23/24 at 2:18 p.m. with Director of Staffing Development (DSD), CNAs 1, 2, 3, 4 and CNAL's personnel folders were reviewed. DSD stated CNA 1's personnel folder indicated their last Annual Performance Evaluation was 4/22/23. DSD stated CNA 2's personnel folder indicated their last Annual Performance Evaluation was 10/12/23. DSD stated CNA 3's personnel folder indicated their last Annual Performance Evaluation was 6/28/23. DSD stated CNA 4's personnel folder…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-10-25 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure medications were appropriately acquired, received, and dispensed when: 1. One oral (administered by mouth) emergency medication kit (E-Kit) was not replaced within 72 hours after opening. 2. One injectable (medications that are administered into the body using needle and syringe) E-Kit had 15 expired medications. These failures had the potential to result in delayed treatments during emergency situations and placed residents at risks for receiving expired medications. Findings: During a concurrent observation and interview on 10/22/24 at 3:40 p.m. during an inspection of the E-kit, in the medication room, with Licensed Vocational Nurse (LVN) 2, there were two E-kits in the medication room. The first E-kit containing oral medications was noted to have been opened and sealed with red plastic ties, and a medication was last used on 10/9/24. According to LVN 2, the red plastic ties indicated the E-kit had been opened and used. LVN 2 stated they notified pharmacy on 10/9/24, but Pharmacy still had not…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-10-25 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. During the medication pass, two medication errors were observed out of 33 opportunities for two of four residents ((Resident 16, Resident 24) resulting in an error rate of 6.06 percent. 1. Mirabegron (medication for overactive bladder) extended release 25 mg 1 tablet oral (by mouth) was crushed and administered to Resident 16. 2. Timolol maleate eye drops were not properly administered to Resident 24. These deficient practices resulted in medication not given in accordance with the manufacturer's specifications and per the standard professional practice, which may result in residents not receiving the full therapeutic effects of the medications. Findings: 1. During a medication pass observation (a process through which medication is administered to the resident) on 10/22/24 at 10:02 a.m., Licensed Vocational Nurse (LVN) 1 crushed mirabegron ER (extended release- medication that allows the body to feel the effects of the specific medication over a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-10-25 · tag F0801 — pattern
  Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to employ a full time Dietary Manager (DM) while they had a part time Registered Dietician (RD). This failure had the potential to result in inadequate resident kitchen oversight and placed 32 residents who received food from the kitchen, at risk to receive inadequate nutrition. Findings: During an interview on 10/21/24 at 2:09 p.m. with DM, DM stated they worked part time. DM stated they normally worked about 30 hours a week. During an interview on 10/22/24 at 10:38 a.m. with RD, RD stated they worked part time. RD stated they usually worked once a month for six to eight hours on site and consult remotely as needed. During an interview on 10/24/24 at 2:02 p.m. with RD, RD stated it was important to have a DM to make sure kitchen staff were following sanitation rules and regulations and to make sure they are following residents' diets and choices. During an interview on 10/24/24 at 12:07 p.m. with Administrator (ADM), ADM stated DM worked about 30 hrs. a week. During an interview on 10/25/24 at 11:20 a.m. with ADM, ADM stated…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-10-25 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared under sanitary conditions when: 1. The freezer had three food items not labeled with date. 2. The freezer had two food items unsealed and open to air. 3. Staff did not wear a beard restraint while preparing resident food. 4. Resident refrigerator had three unlabeled and undated food items. 5. Six dry foods were stored less than 6 inches above the ground. 6. One expired canned food was available for resident use. 7. The refrigerator had one box of rotten bell peppers. These failures had the potential to put 32 residents at risk for cross contamination and food borne illnesses. Findings: During a concurrent observation and interview on 10/21/24, at 9:29 a.m. with [NAME] (CK) 1, the walk-in freezer was observed. The freezer had one box of Danish pastries opened to air and not sealed, one closed package of waffles that was not labeled with date, one opened package of waffles that was not labeled with date, and one package of pot roast was opened to air, unsealed, and not…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-10-25 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to follow infection control practices for three (Resident 2, Resident 4, and Resident 16) of 34 sampled residents when licensed staff did not sanitize the reusable medication tray in between use for the residents and did not perform hand hygiene in between medication pass for Resident 16. These failures had the potential to result in cross contamination and spread of infection. Findings: During a medication (med) pass observation on 10/22/24 at 9:20 a.m. with LVN 1, LVN 1 prepared Resident 2's medications in a medicine cup, put them in the med tray and administered the medications to Resident 2 in her room. LVN 1 proceeded to the bathroom to wash his hands and took the med tray along. LVN 1 set the med tray on top of the sink and washed his hands, then took the med tray and exited Resident 2's room. LVN 1 placed the med tray on the med cart without sanitizing the med tray and continued to prepare the next resident (Resident 4)'s medications in the same med tray. During a med pass observation on 10/22/24 at 10:10…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2023-11-02 · tag F0801 — widespread
  Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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, [NAME] stated he was going to puree the meatloaf. [NAME] placed sliced cooked meatloaf in a blender, added hot, steaming, clear liquid, which he stated was water, and turned on the blender. [NAME] poured some of the blender contents into a cup and poured the remainder into a container on the steam table. The blender contents were a light brown liquid with a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2023-11-02 · tag F0805 — failed to prepare food in a form residents can eat — widespread
  Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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, [NAME] stated he was going to puree the meatloaf. [NAME] placed sliced cooked meatloaf in a blender, added hot, steaming, clear liquid, which he stated was water, and turned on the blender. [NAME] poured some of the blender contents into a cup and poured the remainder into a container on the steam table. The blender contents were a light brown liquid with a thin, watery consistency. [NAME] stated the blended meatloaf poured into the cup was for a facility resident on a liquid diet. [NAME] stated the blended meatloaf in the steam…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2023-11-02 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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. Admin stated it was important to test for Legionella because residents could be at risk for water-borne pathogens. Admin stated there was no facility policy regarding Legionella testing since the facility did not test for Legionella. During an interview on 11/01/23 at 1:02 p.m., with Maintenance Director (MTD), MTD stated he did not test for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

CMS files one row per role, so the 12 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in CA