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