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Inspection visit

Health inspection

BETHESDA HOMECMS #0563704 citations on this visit
4 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. 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 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 table container was for the 12 facility residents were on a pureed diet. [NAME] stated the blended meatloaf mixture was too watery a consistency for residents on a pureed diet. [NAME] pointed to a container of thickener and stated he would need to thicken the meatloaf mixture on the steam table. During a concurrent observation and interview on 10/30/23, at 11:37 a.m., in the kitchen, [NAME] stated he was going to puree the vegetables. [NAME] placed cooked vegetables in a blender and added a golden-colored, thin liquid, which he stated was chicken broth, 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 green liquid with a thin, watery consistency. [NAME] stated the blended vegetables in the cup were for the facility resident on a liquid diet. [NAME] stated the vegetable mixture on the steam table would be thickened for the 12 facility residents on pureed diets. During a concurrent observation and interview on 10/31/23, at 11:30 a.m., in the kitchen, [NAME] stated he was going to puree peas. [NAME] placed six heaping green handled scoops of peas in a blender. [NAME] added five black handled scoops of chicken broth to the peas 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. [NAME] stated the blended peas in the cup was for the resident on a liquid diet. [NAME] (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 7 Event ID: 056370 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stated the blended peas in the container on the steam table would be thickened for the 13 residents on pureed diets. [NAME] stated another resident in the facility had been placed on a pureed diet since yesterday. During a concurrent observation and interview on 10/31/23, at 11:35 a.m., in the kitchen, [NAME] stated he was going to puree baked potatoes. [NAME] put four baked potatoes in a blender, added seven black handled scoops of chicken broth, 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 white liquid with a thin, watery consistency. [NAME] stated the cup of blended potatoes was for the resident on a liquid diet. [NAME] stated he would thicken the container of blended potatoes on the steam table for the 13 residents on pureed diets. During a concurrent observation and interview on 10/31/23, at 11:40 a.m., in the kitchen, [NAME] stated he was going to puree baked chicken. [NAME] placed eight chicken thighs in a blender, added six black handled scoops of chicken stock, and six black handled scoops of gravy, 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 beige liquid with a thin, watery consistency. [NAME] stated the cup of blended chicken was for the resident on a liquid diet. [NAME] stated he would thicken the container of blended chicken on the steam table for the 13 residents on pureed diets. During an interview on 10/31/23, at 11:45 a.m., with Cook, [NAME] stated the facility did not have recipes to make pureed food. During an interview on 10/31/23, at 11:47 a.m., with Assistant Kitchen Supervisor (ADS), ADS stated the facility did not have recipes to make pureed food. During an interview on 11/1/23, at 12:52 p.m., with ADS, ADS stated he had promoted in May 2023 from the position of a cook to Assistant Kitchen Supervisor. ADS stated he was in the process of completing a course for dietary manager certification. ADS stated he had not completed the necessary training and education for certification as a dietary manager. ADS stated he had just been made aware of the existence of facility recipes for pureed food. During a concurrent record review, the facility recipes for pureeing meats, potatoes, and vegetables were reviewed. ADS stated [NAME] had not followed the puree recipes for the meat, potatoes, and vegetables on 10/30/23 and 10/31/23. ADS stated [NAME] had not pureed the food on low speed before adding any liquid, had not blended the foods to the correct consistency, and had added more liquid than the recipe required. During a review of the recipe for pureed meats, the pureed meat recipe indicated, .Puree on low speed to a paste consistency before adding any liquid. Gradually add warm liquid. Puree should reach a consistency slightly softer than whipped topping. During a review of the recipe for pureed vegetables, the pureed vegetables recipe indicated, .Puree on low speed to a paste consistency before adding any liquid. Gradually add warm liquid . if needed Puree should reach the consistency of applesauce . During a review of the recipe for pureed starch (rice, pasta, and potatoes), the pureed starch recipe indicated, .Puree on low speed to a paste consistency before adding any liquid. Gradually add warm milk . Puree should reach a consistency slightly softer than whipped topping During an interview on 11/2/2023, at 8:10 a.m., with Administrator (ADM), ADM stated the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete did not employ a qualified Dietary Manager. ADM stated the facility had promoted ADS to Assistant Dietary Supervisor when the Dietary Manager quit. ADM stated ADS had not completed the training and educational requirements necessary for a qualified dietary manager. During an interview on 11/2/2023, at 9:15 a.m., with Registered Dietitian (RD), RD stated she worked at the facility eight hours per week. RD stated kitchen staff were required to follow the puree diet recipes. RD stated when kitchen staff did not follow the puree recipes, the nutritional content of the pureed food was unknown, which put residents on pureed diets at risk of receiving inadequate nutrition. Event ID: Facility ID: 056370 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. 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 table container was for the 12 facility residents were on a pureed diet. [NAME] stated the blended meatloaf mixture was too watery a consistency for residents on a pureed diet. [NAME] pointed to a container of thickener and stated he would need to thicken the meatloaf mixture on the steam table. During a concurrent observation and interview on 10/30/23, at 11:37 a.m., in the kitchen, [NAME] stated he was going to puree the vegetables. [NAME] placed cooked vegetables in a blender and added a golden-colored, thin liquid, which he stated was chicken broth, 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 green liquid with a thin, watery consistency. [NAME] stated the blended vegetables in the cup were for the facility resident on a liquid diet. [NAME] stated the vegetable mixture on the steam table would be thickened for the 12 facility residents on pureed diets. During a concurrent observation and interview on 10/31/23, at 11:30 a.m., in the kitchen, [NAME] stated he was going to puree peas. [NAME] placed six heaping green handled scoops of peas in a blender. [NAME] added five black handled scoops of chicken broth to the peas 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. [NAME] stated the blended peas in the cup was for the resident on a liquid diet. [NAME] stated the blended peas in the container on the steam table would be thickened for the 13 residents on pureed diets. [NAME] stated another resident in the facility had been placed on a pureed diet since yesterday. During a concurrent observation and interview on 10/31/23, at 11:35 a.m., in the kitchen, [NAME] stated he was going to puree baked potatoes. [NAME] put four baked potatoes in a blender, added seven black handled scoops of chicken broth, 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 white liquid with a thin, watery consistency. [NAME] stated the cup of blended potatoes was for the resident on a liquid diet. [NAME] stated he would thicken the container of blended potatoes on the steam table for the 13 residents on pureed diets. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a concurrent observation and interview on 10/31/23, at 11:40 a.m., in the kitchen, [NAME] stated he was going to puree baked chicken. [NAME] placed eight chicken thighs in a blender, added six black handled scoops of chicken stock, and six black handled scoops of gravy, 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 beige liquid with a thin, watery consistency. [NAME] stated the cup of blended chicken was for the resident on a liquid diet. [NAME] stated he would thicken the container of blended chicken on the steam table for the 13 residents on pureed diets. During an interview on 10/31/23, at 11:45 a.m., with Cook, [NAME] stated the facility did not have recipes to make pureed food. During an interview on 10/31/23, at 11:47 a.m., with Assistant Kitchen Supervisor (ADS), ADS stated the facility did not have recipes to make pureed food. During an interview and concurrent record review on 11/1/23, at 12:52 p.m., with ADS, the facility recipes for pureeing meats, potatoes, and vegetables were reviewed. ADS stated he had just been made aware of the existence of facility recipes for pureed food. ADS stated [NAME] had not followed the puree recipes for the meat, potatoes, and vegetables on 10/30/23 and 10/31/23. ADS stated [NAME] had not pureed the food on low speed before adding any liquid, had not blended the foods to the correct consistency, and had added more liquid than the recipe required. During a review of the recipe for pureed meats, the pureed meat recipe indicated, .Puree on low speed to a paste consistency before adding any liquid. Gradually add warm liquid. Puree should reach a consistency slightly softer than whipped topping. During a review of the recipe for pureed vegetables, the pureed vegetables recipe indicated, .Puree on low speed to a paste consistency before adding any liquid. Gradually add warm liquid . if needed Puree should reach the consistency of applesauce . During a review of the recipe for pureed starch (rice, pasta, and potatoes), the pureed starch recipe indicated, .Puree on low speed to a paste consistency before adding any liquid. Gradually add warm milk . Puree should reach a consistency slightly softer than whipped topping During an interview on 11/2/2023, at 9:15 a.m., with Registered Dietitian (RD), RD stated she worked at the facility eight hours per week. RD stated kitchen staff were required to follow the puree recipes. RD stated when kitchen staff did not follow the puree recipes, the nutritional content of the pureed food was unknown, which put residents on pureed diets at risk of receiving inadequate nutrition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 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). Residents Affected - Many 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 Legionella because he was unaware preventive measures were needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethesda Home 22427 Montgomery Street Hayward, CA 94541 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide education about pneumococcal vaccinations (an injection to reduce to risk of getting pneumonia; an infection of the lungs) and failed to offer pneumococcal vaccination to three (Resident 30, Resident 1, and Resident 12) of five sampled residents. Residents Affected - Some This failure resulted in lack of knowledge of advantages of pneumococcal vaccination and had the potential to result in increased risk of contracting pneumonia for Resident 30, Resident 1, and Resident 12. Findings: A review of Resident 30's Health Record indicated an admission date in 2021. The immunizations information indicated Resident 30 had received a PPSV-23 (a type of pneumococcal vaccine) in 2009, and PCV-13 (another type of pneumococcal vaccine) in 2017. A review of Resident 1's Health Record indicated an initial admission date in 2017, and a readmission date in 2018. The immunizations information indicated Resident 1 had received PCV-13 in 2018, with no other type of pneumococcal vaccination documented. A review of Resident 12's Health Record indicated an initial admission date in January 2023, and a readmission date in April 2023. The immunizations information indicated Resident 1 had received PPSV-23 in 2018, with no other types of pneumococcal vaccination documented. During a concurrent interview and record review on 11/1/23 at 8:27 a.m., with Infection Preventionist (IP), the Centers for Disease Control and Prevention (CDC) article titled, Pneumococcal Vaccines Timing for Adults, dated 2022, was reviewed. The Pneumococcal Vaccine Timing for Adults indicated the following vaccination schedule: Adults 65 years or older, who received PPSV-23 at any age, should be vaccinated with either PCV 15 or PCV 20 after one year. Adults 65 years or older who received PCV13 at any age, the CDC recommended vaccination with either PCV20 or PPSV23 after one year. For adults who completed the PCV13 at any age and PPSV23 series when they were older than [AGE] years of age, the CDC recommended vaccination with PCV20 after five years. IP stated she thought a resident was supposed to wait five years between pneumococcal vaccinations. IP stated she followed the CDC guidelines but had misunderstood the guidelines. During a concurrent interview and record review on 11/1/23 at 8:45 a.m., with IP, Resident 30's, Resident 1's, and Resident 12's immunization records (undated) were reviewed. IP stated Resident 30 had a pneumococcal vaccine in 2017 and needed to be offered another vaccination. IP stated Resident 1 had last had a pneumococcal vaccination in 2018 and needed to be offered another vaccination. IP stated Resident 12 also needed to be offered another pneumococcal vaccination. During a review of facility's policy and procedure titled, Pneumococcal Vaccine, dated March 2022, the policy and procedure indicated, 7. Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention recommendations . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056370 If continuation sheet Page 7 of 7

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Citations

4 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0801GeneralS&S Fpotential for harm

    F801 - Staffing

    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.

  • 0805GeneralS&S Fpotential for harm

    F805 - Food and drink

    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

  • 0880GeneralS&S Fpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0883GeneralS&S Epotential for harm

    F883 - Influenza and pneumococcal immunizations

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

FAQ · About this visit

Common questions about this visit

What happened during the November 2, 2023 survey of BETHESDA HOME?

This was a inspection survey of BETHESDA HOME on November 2, 2023. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BETHESDA HOME on November 2, 2023?

Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nut..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.