US Nursing Home Finder: BETHESDA HEALTH AND REHABILITATION BETHESDA MD

General Information: BETHESDA HEALTH AND REHABILITATION
Nursing home name	BETHESDA HEALTH AND REHABILITATION
Address	5721 GROSVENOR LANE BETHESDA, MD 20814
Phone number	(301) 530-1600
Located within a hospital	No
Type of ownership	For profit - Corporation
Owner operates multiple homes	Yes
Accept Medicare or Medicaid	Medicare and Medicaid
Continue Care Retirement Community	No
Resident and family councils	RESIDENT
Certified number of beds	200
Total number of residents	153
Perc of occupied beds	77
Sprinkler status	fully sprinklered
Last health survey date	03/02/2009
Fire survey date:	03/18/2009

Ratings Summary: BETHESDA HEALTH AND REHABILITATION
Overall rating	2 out of 5 stars
Nursing Home Staffing	3 out of 5 stars
Registered Nurses only	2 out of 5 stars
Health Inspections	1 out of 5 stars
Quality Measures	5 out of 5 stars

Nursing Home Staffing Info: BETHESDA HEALTH AND REHABILITATION
	National Average	BETHESDA HEALTH AND REHABILITATION
Overall staff rating	Not Available.	3 out of 5 stars
Registered Nurses only rating	Not Available	2 out of 5 stars
Total Number of Residents	94.2	153
Total Number of Licensed Nurse Staff Hours per Resident per Day	1.4 hours	1.66 hours
Registered Nurses Hours per Residents per Day	0.6 hours	0.42 hours
Licensed Practical or Vacation Nurses Hours per Resident per Day	0.8 hours	1.24 hours
Certified Nursing Assistants Hours per Residents per Day	0.6 hours	0.42 hours

Health Inpections: BETHESDA HEALTH AND REHABILITATION
Inspection Results: 03/02/2009
Corrected	Category	Deficiency	Severity
06/02/2009	Administration Deficiencies	Keep accurate and appropriate medical records.	B
04/14/2009	Administration Deficiencies	Follow all laws and professional standards.	D
04/14/2009	Pharmacy Service Deficiencies	Properly mark drugs and other similar products.	D
04/14/2009	Pharmacy Service Deficiencies	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	E
04/14/2009	Pharmacy Service Deficiencies	Make sure that residents are safe from serious medication errors.	E
04/14/2009	Pharmacy Service Deficiencies	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	D
04/14/2009	Quality Care Deficiencies	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	D
06/02/2009	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	E
04/14/2009	Quality Care Deficiencies	Give professional services that meet a professional standard of quality.	G
04/14/2009	Quality Care Deficiencies	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	D
04/14/2009	Resident Rights Deficiencies	Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	D
Inspection Results: 04/11/2008
Corrected	Category	Deficiency	Severity
05/26/2008	Administration Deficiencies	Keep accurate and appropriate medical records.	E
05/26/2008	Quality Care Deficiencies	Develop/implement required procedures for the administration of immunizations.	E
05/26/2008	Pharmacy Service Deficiencies	Make sure that residents are safe from serious medication errors.	E
05/26/2008	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	E
05/26/2008	Quality Care Deficiencies	Give professional services that meet a professional standard of quality.	E
05/26/2008	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	D
05/26/2008	Resident Rights Deficiencies	Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	B
05/26/2008	Resident Rights Deficiencies	Provide written records when a resident is transferred or discharged.	B
05/26/2008	Resident Rights Deficiencies	Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	D
05/26/2008	Resident Rights Deficiencies	Let the resident refuse treatment or refuse to take part in an experiment.	D
Inspection Results: 04/17/2007
Corrected	Category	Deficiency	Severity
08/20/2007	Administration Deficiencies	Keep accurate and appropriate medical records.	B
08/20/2007	Administration Deficiencies	Be administered in a way that leads to the highest possible level of well being for each resident.	E
10/22/2007	Environmental Deficiencies	Keep a resident apart from the others if the resident has an infection that can spread.	D
05/29/2007	Pharmacy Service Deficiencies	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	E
10/22/2007	Pharmacy Service Deficiencies	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	B
11/13/2007	Resident Assessment Deficiencies	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	G
08/20/2007	Quality Care Deficiencies	Use a registered nurse at least 8 hours a day, 7 days a week.	D
05/29/2007	Quality Care Deficiencies	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	G
05/29/2007	Quality Care Deficiencies	Develop/implement required procedures for the administration of immunizations.	D
08/20/2007	Pharmacy Service Deficiencies	Make sure that residents are safe from serious medication errors.	D
08/20/2007	Pharmacy Service Deficiencies	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	G
	Environmental Deficiencies	Make sure that the nursing home area is free of dangers that cause accidents.	E
05/29/2007	Quality Care Deficiencies	Give the right treatment and services to residents who have mental or social problems adjusting.	E
05/29/2007	Quality Care Deficiencies	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	E
05/29/2007	Quality Care Deficiencies	Make sure that each residents' abilities to take care of themselves does not lessen, unless a change cannot be avoided.	B
08/20/2007	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	J
11/13/2007	Quality Care Deficiencies	Give professional services that meet a professional standard of quality.	G
05/29/2007	Mistreatment Deficiencies	1) Hire only people who have 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
10/22/2007	Resident Rights Deficiencies	Try to resolve each resident's complaints quickly.	B
08/20/2007	Resident Rights Deficiencies	Keep each resident's personal and medical records private and confidential.	D
11/13/2007	Resident Rights Deficiencies	Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	E
05/29/2007	Resident Rights Deficiencies	Let the resident refuse treatment or refuse to take part in an experiment.	D

Fire Safety Inpections: BETHESDA HEALTH AND REHABILITATION
Inspection Results: 03/18/2009
Corrected	Category	Deficiency	Severity
04/24/2009	Furnishings and Decorations Deficiencies	exits that are free from obstructions and can be used at all times.	B
04/24/2009	Building Service Equipment Deficiencies	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	D
04/24/2009	Automatic Sprinkler Systems Deficiencies	automatic sprinkler systems that have been maintained in working order.	C
05/05/2009	Fire Alarm Systems Deficiencies	a fire alarm system that can be heard throughout the facility.	D
04/24/2009	Emergency Plans and Fire Drills Deficiencies	record of quarterly fire drills for each shift under varying conditions.	D
04/24/2009	Exits and Egress Deficiencies	exits that are accessible at all times.	B
05/05/2009	Hazardous Area Deficiencies	construction that can resist fire for one hour or an approved fire extinguishing system.	D
04/24/2009	Smoke Compartmentation and Control Deficiencies	smoke barrier doors that can resist smoke for at least 20 minutes.	B
04/24/2009	Corridor Walls and Doors Deficiencies	corridor and hallway doors that block smoke.	C
Inspection Results: 03/19/2008
Corrected	Category	Deficiency	Severity
06/13/2008	Building Service Equipment Deficiencies	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	C
05/30/2008	Miscellaneous Deficiencies	fire safety features required by current fire safety codes.	B
05/30/2008	Medical Gases and Anesthetizing Areas Deficiencies	no-smoking signs where oxygen is used.	B
06/13/2008	Automatic Sprinkler Systems Deficiencies	automatic sprinkler systems that have been maintained in working order.	C
07/01/2008	Fire Alarm Systems Deficiencies	an approved installation, maintenance and testing program for fire alarm systems.	C
06/13/2008	Exits and Egress Deficiencies	exits that are accessible at all times.	E
06/13/2008	Hazardous Area Deficiencies	construction that can resist fire for one hour or an approved fire extinguishing system.	C
06/13/2008	Interior Finish Deficiencies	fire-resistant room wall surfaces.	C
Inspection Results: 03/13/2007
Corrected	Category	Deficiency	Severity
04/30/2007	Miscellaneous Deficiencies	fire safety features required by current fire safety codes.	B
04/30/2007	Medical Gases and Anesthetizing Areas Deficiencies	proper medical gas storage and administration areas.	B
04/30/2007	Automatic Sprinkler Systems Deficiencies	automatic sprinkler systems that have been maintained in working order.	B
04/27/2007	Exits and Egress Deficiencies	exits that are accessible at all times.	B
04/27/2007	Hazardous Area Deficiencies	construction that can resist fire for one hour or an approved fire extinguishing system.	B
04/27/2007	Vertical Openings Deficiencies	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	B

Resident Complaints: BETHESDA HEALTH AND REHABILITATION
Date Complaint Substantiated: 08/10/2009
Corrected	Category	Deficiency	Severity
09/29/2009	Pharmacy Service Deficiencies	Properly mark drugs and other similar products.	B
09/29/2009	Pharmacy Service Deficiencies	Make sure that residents are safe from serious medication errors.	D
Date Complaint Substantiated: 11/05/2008
Corrected	Category	Deficiency	Severity
02/04/2009	Resident Assessment Deficiencies	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	D
Date Complaint Substantiated: 05/30/2007
Corrected	Category	Deficiency	Severity
07/14/2007	Quality Care Deficiencies	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	E
07/14/2007	Quality Care Deficiencies	Make sure that each residents' abilities to take care of themselves does not lessen, unless a change cannot be avoided.	E
Date Complaint Substantiated: 01/30/2007
Corrected	Category	Deficiency	Severity
03/12/2007	Resident Assessment Deficiencies	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	D
03/12/2007	Mistreatment Deficiencies	Protect residents from mistreatment, neglect, and/or theft of personal property.	D
03/12/2007	Resident Rights Deficiencies	Tell the resident completely about his or her health status.	B
Date Complaint Substantiated: 12/13/2006
Corrected	Category	Deficiency	Severity
02/13/2007	Resident Assessment Deficiencies	Make a complete assessment that covers all questions for areas that are listed in official regulations.	D

Quality Measures: BETHESDA HEALTH AND REHABILITATION
Quality Measures	National Average	BETHESDA HEALTH AND REHABILITATION
Overall quality rating	Not Available	5 out of 5 stars
Long-Stay Residents
Percent of long-stay residents whose ability to move about in and around their room got worse	11%	3%
Percent of long-stay residents who lose too much weight	8%	2%
Percent of low-risk long-stay residents who lose control of their bowels or bladder	50%	55%
Percent of long-stay residents who had a urinary tract infection	9%	7%
Percent of long-stay residents who were assessed and given pneumococcal vaccination	89%	90+%
Percent of long-stay residents who have/had a catheter inserted and left in their bladder	5%	3%
Percent of long-stay residents who spend most of their time in bed or in a chair	4%	2%
Percent of long-stay residents who were physically restrained	3%	1%
Percent of long-stay residents who have moderate to severe pain	3%	1%
Percent of long-stay residents who are more depressed or anxious	14%	15%
Percent of long-stay residents given influenza vaccination during the flu season	91%	90+%
Percent of long-stay residents whose need for help with daily activities has increased	14%	3%
Percent of high-risk long-stay residents who have pressure sores	11%	10%
Percent of low-risk long-stay residents who have pressure sores	2%	0%
Short-Stay Residents
Percent of short-stay residents who were assessed and given pneumococcal vaccination	83%	90+%
Percent of short-stay residents who have pressure sores	13%	15%
Percent of short-stay residents who had moderate to severe pain	19%	3%
Percent of short-stay residents given influenza vaccination during the flu season	83%	80%
Percent of short-stay residents who have delirium	2%	0%

Severity Codes Explanation. Note: The higher the letter, the higher the severity.
A	Isolated /Potential for minimal harm
B	Pattern /Potential for minimal harm
C	Widespread /Potential for minimal harm
D	Isolated /Minimal harm or potential for actual harm
E	Pattern /Minimal harm or potential for actual harm
F	Widespread /Minimal harm or potential for actual harm
G	Isolated /Actual harm
H	Pattern /Actual harm
I	Widespread /Actual harm
J	Isolated /Immediate jeopardy to resident health or safety
K	Pattern /Immediate jeopardy to resident health or safety
L	Widespread /Immediate jeopardy to resident health or safety

US Nursing Home Finder™: BETHESDA HEALTH AND REHABILITATION BETHESDA MD