General Information: BETHESDA HEALTH AND REHABILITATION
Nursing home name BETHESDA HEALTH AND REHABILITATION
Address5721 GROSVENOR LANE
BETHESDA, MD 20814
Phone number (301) 530-1600
Located within a hospital No
Type of ownership For profit - Corporation
Owner operates multiple homesYes
Accept Medicare or Medicaid Medicare and Medicaid
Continue Care Retirement CommunityNo
Resident and family councils Resident
Certified number of beds 200
Total number of residents 173
Perc of occupied beds 86
Sprinkler status Yes
Number of Facility Reported Incidents1
Number of Substantiated Complaints13
Number of Fines0
Total Amount of Fines$0
Total Number of Penalties0
Total Number of Penalties0
Ratings Summary: BETHESDA HEALTH AND REHABILITATION
Overall rating 2
2
Nursing Home Staffing 4
4
Registered Nurses only 3
3
Health Inspections 1
1
Quality Measures 5
5
Nursing Home Staffing Info: BETHESDA HEALTH AND REHABILITATION
National AverageMaryland AverageBETHESDA HEALTH AND REHABILITATION
Overall staff rating NA NA 4
4
Registered Nurses only rating NANA 3
3
Total Number of Residents NA NA 173
Total Number of Nurse Staff Hours per Resident per Day 4.11 hours 4.24 hours 4.45 hours
Total Number of Licensed Nurse Staff Hours per Resident per Day 1.64 hours 1.82 hours 2.12 hours
Registered Nurses Hours per Residents per Day 0.81 hours 0.9 hours 0.67 hours
Licensed Practical or Vacation Nurses Hours per Resident per Day 0.83 hours 0.91 hours 1.45 hours
Certified Nursing Assistants Hours per Residents per Day 2.47 hours 2.42 hours 2.33 hours
Physical Therapy Staffing Hours per Resident Per Day 0.1 hours 0.13 hours 0.16 hours
Health Survey: BETHESDA HEALTH AND REHABILITATION
Heath Survey Summary on 2013-03-14
Total Number of Health Deficiencies 16
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Heath Survey Summary on 2012-05-08
Total Number of Health Deficiencies 18
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Heath Survey Summary on 2011-04-14
Total Number of Health Deficiencies 12
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Health Survey Details: BETHESDA HEALTH AND REHABILITATION
Inspection Results: 03/14/2013
Corrected Deficiency Scope and Severity
04/19/2013 Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated/Minimal harm or potential for actual harm
04/19/2013 Conduct initial and periodic assessments of each resident's functional capacity. Pattern/Minimal harm or potential for actual harm
04/19/2013 Completely assess the resident at least every twelve months. Pattern/Potential for minimal harm
04/19/2013 Assure that each residents assessment is updated at least once every 3 months. Pattern/Potential for minimal harm
04/19/2013 Ensure each resident receives an accurate assessment by a qualified health professional. Isolated/Minimal harm or potential for actual harm
04/19/2013 Ensure services provided by the nursing facility meet professional standards of quality. Pattern/Minimal harm or potential for actual harm
04/19/2013 Encode each residents assessment data and transmit these data to the State within 7 days of assessment. Pattern/Potential for minimal harm
04/19/2013 Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern/Minimal harm or potential for actual harm
04/19/2013 Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. Isolated/Minimal harm or potential for actual harm
04/19/2013 Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Pattern/Minimal harm or potential for actual harm
04/19/2013 Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern/Minimal harm or potential for actual harm
04/19/2013 Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern/Minimal harm or potential for actual harm
04/19/2013 At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated/Minimal harm or potential for actual harm
04/19/2013 Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated/Minimal harm or potential for actual harm
04/19/2013 Have a program that investigates, controls and keeps infection from spreading. Pattern/Minimal harm or potential for actual harm
04/19/2013 Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated/Minimal harm or potential for actual harm
Inspection Results: 05/08/2012
Corrected Deficiency Scope and Severity
06/20/2012 Ensure services provided by the nursing facility meet professional standards of quality. Pattern/Minimal harm or potential for actual harm
06/20/2012 Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated/Minimal harm or potential for actual harm
06/20/2012 Give or get emergency care by a doctor 24 hours a day. Isolated/Minimal harm or potential for actual harm
06/20/2012 Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Pattern/Minimal harm or potential for actual harm
06/20/2012 Ensure residents maintain acceptable nutritional status. Pattern/Minimal harm or potential for actual harm
06/20/2012 Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern/Minimal harm or potential for actual harm
06/20/2012 Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern/Minimal harm or potential for actual harm
06/20/2012 Allow residents the right to participate in the planning or revision of care and treatment. Isolated/Minimal harm or potential for actual harm
06/20/2012 Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated/Minimal harm or potential for actual harm
06/20/2012 Conduct initial and periodic assessments of each resident's functional capacity. Isolated/Minimal harm or potential for actual harm
06/20/2012 Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated/Minimal harm or potential for actual harm
06/20/2012 Keep residents' personal and medical records private and confidential. Isolated/Minimal harm or potential for actual harm
06/20/2012 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern/Minimal harm or potential for actual harm
06/20/2012 Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated/Minimal harm or potential for actual harm
06/20/2012 Have a program that investigates, controls and keeps infection from spreading. Isolated/Minimal harm or potential for actual harm
06/20/2012 Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern/Potential for minimal harm
06/20/2012 Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated/Minimal harm or potential for actual harm
06/20/2012 Operate and provide services according to Federal, State, and local laws and professional standards. Pattern/Potential for minimal harm
Inspection Results: 04/14/2011
Corrected Deficiency Scope and Severity
04/15/2011 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated/Minimal harm or potential for actual harm
04/15/2011 Give notice to the resident before a room or roommate change. Pattern/Potential for minimal harm
04/15/2011 Conduct initial and periodic assessments of each resident's functional capacity. Pattern/Minimal harm or potential for actual harm
04/15/2011 Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern/Minimal harm or potential for actual harm
04/15/2011 Allow residents the right to participate in the planning or revision of care and treatment. Pattern/Potential for minimal harm
04/15/2011 Ensure services provided by the nursing facility meet professional standards of quality. Pattern/Minimal harm or potential for actual harm
04/15/2011 Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated/Minimal harm or potential for actual harm
04/15/2011 Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern/Potential for minimal harm
04/15/2011 Store, cook, and serve food in a safe and clean way. Pattern/Potential for minimal harm
04/15/2011 At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated/Minimal harm or potential for actual harm
04/15/2011 Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated/Minimal harm or potential for actual harm
04/15/2011 Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern/Potential for minimal harm

Fire Safety Survey: BETHESDA HEALTH AND REHABILITATION
Fire Safety Survey Summary on 2013-03-14
Total Number of Fire SafetyDeficiencies 0
Scope and Severity of most Severe Health Deficiency
Fire Safety Survey Summary on 2012-05-08
Total Number of Fire SafetyDeficiencies 0
Scope and Severity of most Severe Health Deficiency
Fire Safety Survey Summary on 2011-03-24
Total Number of Fire SafetyDeficiencies 5
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Fire Safety Survey: BETHESDA HEALTH AND REHABILITATION
Fire Safety Survey Results: 03/24/2011
Corrected Deficiency Severity
05/16/2011 Properly installed electrical wiring and equipment. Widespread/Potential for minimal harm
05/16/2011 Other fire safety features required by fire safety codes. Isolated/Minimal harm or potential for actual harm
05/16/2011 Portable fire extinguishers. Widespread/Potential for minimal harm
05/16/2011 Automatic sprinkler systems that have been maintained in working order. Pattern/Minimal harm or potential for actual harm
05/16/2011 Fire resistant room wall surfaces. Widespread/Potential for minimal harm

Resident Complaints: BETHESDA HEALTH AND REHABILITATION
Date Complaint Substantiated: 01/29/2014
CorrectedCategoryDeficiencySeverity
03/15/2014Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. E
03/15/2014Try to resolve each resident's complaints quickly. E
03/15/20141) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. D
03/15/2014Provide housekeeping and maintenance services. D
03/15/2014Conduct initial and periodic assessments of each resident's functional capacity. E
03/15/2014Ensure each resident receives an accurate assessment by a qualified health professional. D
03/15/2014Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D
03/15/2014Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. E
03/15/2014Keep accurate, complete and organized clinical records on each resident that meet professional standards. D
03/15/2014Ensure laboratory services, blood blanks and transfusion services provided on site meet requirements for certified laboratories; or have an agreement to obtain services from an offsite laboratory, that meets the same requirements. D
03/15/2014Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. E
03/15/2014At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. E
03/15/2014Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. D
03/15/2014Provide or obtain dental services for each resident. E
03/15/2014Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. E
03/15/2014Allow residents the right to participate in the planning or revision of care and treatment. E
03/15/2014Develop policies and procedures for influenza and pneumococcal immunizations. D
03/15/2014Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. E
03/15/2014Ensure services provided by the nursing facility meet professional standards of quality. E
03/15/2014Ensure residents maintain acceptable nutritional status. E
03/15/2014Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. E
03/15/2014Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. G
03/15/2014Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. E
03/15/2014Provide necessary care and services to maintain or improve the highest well being of each resident . G
03/15/2014Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. D
Date Complaint Substantiated: 08/29/2013
CorrectedCategoryDeficiencySeverity
10/03/2013Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. E
10/03/2013Ensure services provided by the nursing facility meet professional standards of quality. D
10/03/2013Post nurse staffing information/data on a daily basis. C
10/03/2013Provide clean bed and bath linens that are in good condition. C
Date Complaint Substantiated: 08/14/2013
CorrectedCategoryDeficiencySeverity
09/04/20131) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. E
Date Complaint Substantiated: 11/26/2012
CorrectedCategoryDeficiencySeverity
01/05/2013Upon the death of a resident, convey the residents personal funds and an accounting of those funds to the appropriate party. B
01/05/2013Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. B
Date Complaint Substantiated: 07/11/2012
CorrectedCategoryDeficiencySeverity
Ensure services provided by the nursing facility meet professional standards of quality. B
Date Complaint Substantiated: 02/10/2012
CorrectedCategoryDeficiencySeverity
03/15/2012Provide necessary care and services to maintain or improve the highest well being of each resident . B
Date Complaint Substantiated: 01/17/2012
CorrectedCategoryDeficiencySeverity
03/02/20121) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. D
03/02/2012Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. E
Date Complaint Substantiated: 11/18/2011
CorrectedCategoryDeficiencySeverity
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. B

Quality Measures: BETHESDA HEALTH AND REHABILITATION
Quality Measures National Average Maryland Average BETHESDA HEALTH AND REHABILITATION
Overall quality rating NA NA 5
5
Long-Stay Residents
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased 15.4% 18.1% 8.5%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain 8.3% 5.2% 4.3%
Percent of High Risk Long Stay Residents With Pressure Ulcers 6.1% 7.1% 7.3%
Percent of Long Stay Residents Who Lose Too Much Weight 7.2% 6.2% 2.2%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder 43.9% 53.2% 57.4%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder 3.2% 2.6% 1.1%
Percent of Long Stay Residents With a Urinary Tract Infection 6.2% 5.2% 5.7%
Percent of Long Stay Residents Who Have Depressive Symptoms 6.3% 3.8% 0.9%
Percent of Long Stay Residents Who Were Physically Restrained 1.4% 0.9% 0.0%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury 3.2% 2.6% 0.9%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine 92.7% 92.8% 98.0%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 94.3% 94.8% 98.7%
Percent of Long Stay Residents Who Received an Antipsychotic Medication 20.7% 16.4% 13.1%
Short-Stay Residents
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain 19.2% 14.5% 7.9%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened 1.2% 1.1% 0.3%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine 83.4% 82.9% 97.4%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 82.4% 83.1% 96.4%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication 2.6% 2.3% 3.4%

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