Inspection visit
Inspection
20 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 20 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
resident and staff interviews, review of a resident concern form, and review of facility policy, the facility
failed to ensure residents were treated with dignity and respect. This affected three (Residents #21, #28,
and #42) of three reviewed for dignity. The facility census was 63.
Findings include:
1. Review of Resident #21's medical record revealed an admission date of 12/21/22. Diagnoses included
chronic obstructive pulmonary disease (COPD), emphysema, type II diabetes, history of falling, muscle
weakness, obesity, displaced bimalleolar fracture of left lower leg, subsequent encounter for closed fracture
with routine healing, dependence on supplemental oxygen, congestive heart failure (CHF), chronic kidney
disease, depression, osteoporosis, atrial fibrillation, hypertension, Alzheimer's disease, and fibromyalgia.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was
cognitively intact and required extensive assistance with bed mobility, dressing, and toilet use and total
dependence for transfers.
Interview on 04/24/23 at 10:27 A.M. with Resident #21 revealed the facility had an agency State Tested
Nurse Aide (STNA), she believed STNA #480, who worked over the weekend. Resident #21 stated STNA
#480 was not kind and, if the resident requested assistance, STNA #480 would respond and state things
like, I just changed you. Resident #21 stated STNA #480 would speak in an elevated tone. Although
Resident #21 could not hear exactly what was being said, she stated STNA #480 was loud with another
resident down the hall over the weekend. Resident #21 stated she did not like asking STNA #480 for help.
2. Review of Resident #28's medical record revealed an admission date of 02/25/22 and a readmission
date of 04/21/23. Diagnoses included type II diabetes, acquired absence of right leg above knee, chronic
obstructive pulmonary disease (COPD), encounter for orthopedic aftercare following surgical amputation,
anxiety disorder, chronic kidney disease, dependence on renal dialysis, and congestive heart failure (CHF).
Review of the quarterly MDS dated [DATE] revealed Resident #28 was cognitively intact and required
extensive assistance with bed mobility, dressing, toilet use, and personal hygiene.
Interview on 04/24/23 at 4:11 P.M. with Resident #28 revealed STNA #480 was sometimes rude and short
with her. Resident #28 stated STNA #480 would say things like, What do you want? I was just in
(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 10
Event ID:
365510
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
365510
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bethesda Care Center
600 N Brush St
Fremont, OH 43420
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 0550
here. Resident #28 stated she did not like working with STNA #480.
Level of Harm - Minimal harm
or potential for actual harm
3. Review of Resident #42's medical record revealed an admission date of 06/01/22. Diagnoses included
congestive heart failure (CHF), type II diabetes, morbid obesity, osteoarthritis, anxiety disorder, major
depressive disorder, and hypertension.
Residents Affected - Few
Review of the quarterly MDS dated [DATE] revealed Resident #42 was cognitively intact and required
extensive assistance with Activities of Daily Living (ADLs).
Interview on 04/24/23 at 10:00 A.M. with Resident #42 revealed STNA #480 was not kind and did not treat
residents well. Resident #42 stated on 04/21/23, she had been incontinent in her bed. Resident #42 stated
STNA #480 responded to the call light and Resident #42 told her she was soaking wet. Resident #42 stated
STNA #480 told her it was a little wet spot and she was not soaking wet. STNA #480 left the room, stating
she was getting a witness that she provided care because Resident #42 was not going to accuse her of not
changing her. Resident #42 stated STNA #480 was loud during the interaction. Resident #42 stated she did
not want STNA #480 working with her.
Interview on 04/24/23 at 10:43 A.M. with the Administrator and Director of Nursing (DON) revealed a
resident had filed a grievance on 04/18/23 related to STNA #480's interactions with her. The Administrator
stated he provided education to STNA #480 on 04/19/23 and he and the DON had not been made aware of
any negative interactions over the weekend.
Interview on 04/24/23 at 12:16 P.M. with STNA #480 confirmed she worked this past Friday and Saturday.
STNA #480 stated she was an agency staff member who had been working at the facility for about one
year. STNA #480 confirmed a resident had concerns related to her interactions with her. STNA #480
verified she had made statements such as What do you need? I was just in here and You are going to have
to wait because I am in the middle of something. STNA #480 stated she never intentionally said anything to
be mean or unkind to the residents. STNA #480 stated she did not recall anything specific to this past
weekend. STNA #480 confirmed the Administrator did provide education on 04/19/23 related to her
approach with residents.
Review of a Grievance/Concern Form dated 04/18/23 revealed Resident #21 had several interactions with
a particular STNA who had been short and dismissive. Resident #21 recalled a time when she activated
her call light for personal hygiene and explained to the STNA what she needed. The STNA responded, I
just changed you. Resident #21 stated she was not able to control the frequency of her bowel and bladder
and that was an example of negative interactions. Resident #21 stated she avoided asking the STNA for
assistance with care. Further review revealed the Administrator provided education to STNA #480 on
04/19/23.
Review of facility policy titled, Resident's [NAME] of Rights and Dignity Policy, revised 10/24/22 revealed the
facility must enforce and ensure resident rights are enforced, including the resident has the right to a
dignified existence and the facility must treat each resident with respect and dignity and care for each
resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality
of life, recognizing each resident's individuality.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365510
If continuation sheet
Page 2 of 10
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
365510
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bethesda Care Center
600 N Brush St
Fremont, OH 43420
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 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, and interview, the facility failed to ensure bilateral grab bars were in
place on a resident's bed per physician orders. This affected one (Resident #25) of two residents reviewed
for position and mobility. The facility census was 63.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #25 had an admission date of 07/12/13. Diagnoses
included Alzheimer's disease, dementia, and osteoarthritis.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had
impaired cognition. Resident #25 required the extensive assistance of one staff for bed mobility and
transfers.
Review of a physician order dated 05/04/22 revealed the resident had an order for bilateral grab/transfer
bars to the bed to facilitate independence.
Review of the most recent physical device data collection evaluation dated 04/18/23 revealed the left and
right grab bar on the bed assisted the resident with independent repositioning in bed.
Observations on 04/25/23 at 7:42 A.M. and 10:34 A.M. revealed there were no grab bars on Resident #25's
bed.
Interview on 04/25/23 at 7:42 A.M. Resident #25 revealed she wanted the grab bars to help her move
around in the bed.
Observation on 04/26/23 7:49 A.M. revealed there was one grab bar on right side of bed.
Interview on 04/26/23 at 7:56 A.M. with State Tested Nursing Assistant (STNA) #481 verified there was one
grab bar on the bed.
Interview on 04/26/23 at 8:10 A.M., the Director of Nursing (DON) verified the resident had no grab bars on
her bed until one grab bar was applied today. The DON verified the resident previously had bilateral grab
bars. The DON revealed due to COVID, there had been several room changes. The DON further revealed
maintenance was doing assessments on resident rooms and beds to ensure appropriate devices were
back in place.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365510
If continuation sheet
Page 3 of 10
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
365510
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bethesda Care Center
600 N Brush St
Fremont, OH 43420
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 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Level of Harm - Minimal harm
or potential for actual harm
Based on Beneficiary Protection Notification Review and staff interview, the facility failed to ensure
Advanced Beneficiary of Non-Coverage (ABN) notifications were issued to residents who remained in the
facility following termination of Medicare Part A services. This affected two (Residents #21 and #40) of
three residents reviewed for beneficiary notice protection. The facility census was 63.
Residents Affected - Few
Findings include:
1. Review of Resident #21's Beneficiary Protection Notification revealed the resident's last covered day of
Medicare Part A services was 03/03/23. The facility issued the Notice of Medicare Non-Coverage (NOMNC)
on 02/28/23. A Advanced Beneficiary of Non-Coverage (ABN) was not issued by the facility, with a notation
Resident #21 remained in the facility under Medicaid.
2. Review of Resident #40's Beneficiary Protection Notification revealed the resident's last covered day of
Medicare Part A services was 04/07/23. The facility issued the NOMNC on 04/05/23. An ABN was not
issued by the facility, with a notation Resident #40 remained in the facility under Medicaid.
Interview on 04/25/23 at 2:01 P.M. of Business Office Manager (BOM) #426 confirmed she was responsible
for issuing beneficiary notices. BOM #426 verified ABN notices were not provided to Residents #21 and
#40, stating the residents were not incurring costs because Medicaid was paying for their stay after
Medicare Part A services stopped.
Review of facility policy titled, SNF ABN (Advanced Beneficiary Notice) Policy and Procedure, revised
September 2022, revealed the ABN was issued before providing care or services that do not meet
Medicare coverage criteria, for example, the resident was covered by Medicare Part A but is going to stay
at the nursing home for custodial care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365510
If continuation sheet
Page 4 of 10
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
365510
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bethesda Care Center
600 N Brush St
Fremont, OH 43420
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, staff interview, resident interview, and review of facility policy, the facility
failed to ensure residents were provided an environment with comfortable sound levels. This affected one
(Resident #22) of three reviewed for comfortable sound levels. The facility census was 63.
Findings include:
Review of Resident #22's medical record revealed an admission date of 10/24/19. Diagnoses included type
II diabetes, cognitive communication deficit, legally blind, history of lung cancer, history of skin cancer,
history of bladder cancer, major depressive disorder, mild cognitive impairment, and hearing loss.
Review of Resident #22's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental
Status (BIMS) score of eight, indicating Resident #22 was moderately cognitively impaired. Resident #22
was independent or required set up only with all of his activities of daily living. Resident #22 had moderate
difficulty with hearing. Resident #22 was able to make himself understood and usually understood others.
Review of Resident #22's care plan revised 02/20/23 revealed supports and interventions for hearing.
Resident #22 had zero hearing in his right ear and was hard of hearing in his left ear.
Review of Resident #22's census information revealed Resident #22 resided in one of the rooms closest to
the laundry room.
Observation throughout the day on 04/24/23 and 04/25/23 found Resident #22 seated in the central
common area of the facility.
Observation on 04/26/23 at 8:13 A.M. of the laundry room at the end of the 400 hallway found the two
washing machines were running and making a very loud squealing noise which made it difficult to
converse.
Interview on 04/26/23 at 8:14 A.M. with Housekeeper (HK) #441 verified the washing machine squealing
was very loud and it was difficult to hear. HK #441 reported they tried to keep the door closed when
washing clothes to try not to bother the residents.
Interview on 04/26/23 at 8:15 A.M. with HK #411 also verified the washing machines were loud when
running. HK #411 reported they had a contracted maintenance company for washing machine repairs. HK
#411 reported they had not been contacted for the washing machine's loud squealing sound. HK #411
reported Resident #22 was the only resident who had complained about the laundry room noises. HK #411
reported he had complained to them, maintenance, and the aides.
Observation on 04/26/23 at 9:58 A.M. of Resident #22 found him seated in a wheelchair in the common
area.
Interview on 04/26/23 at 10:01 A.M. with Resident #22 verified the noise from the laundry room bothered
him. Resident #22 reported he spent a lot of time in the common area to get away from the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365510
If continuation sheet
Page 5 of 10
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
365510
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bethesda Care Center
600 N Brush St
Fremont, OH 43420
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
laundry room noise. Resident #22 reported it was not as bad if they closed the door, but he could still hear
it. Resident #22 reported he was completely deaf in one ear and hard of hearing in the other so the sound
had to be loud.
Review of the facility policy titled, Resident's [NAME] of Rights, revised 10/24/22 revealed the facility must
treat each resident with respect and dignity in an environment that promotes maintenance or enhancement
of her or her quality of life.
Event ID:
Facility ID:
365510
If continuation sheet
Page 6 of 10
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
365510
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bethesda Care Center
600 N Brush St
Fremont, OH 43420
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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Residents Affected - Few
Based on record review, interview, and review of facility policy, the facility failed to provide care and services
to potentially prevent additional and/or worsening pressure ulcers. This affected one (Resident #34) of two
residents reviewed for pressure ulcers. The facility census was 63.
Findings included:
Review of the medical record for Resident #34 revealed an admission date of 01/18/23, diagnoses included
heart failure, osteoarthritis, dementia, with mood disturbance, anxiety disorder, hypoxemia, iron deficiency
anemia, hypertension, hearing loss, and diverticulosis.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had
impaired cognition, required the extensive assistance of two staff for bed mobility, transfers and toilet use,
and the extensive assistance of one staff for walking, locomotion, dressing, and personal hygiene. Resident
#34 used a wheelchair and walker for mobility. Resident #34 was occasionally incontinent of bowel and
bladder, had no skin breakdown, and was identified as at risk for skin breakdown.
Review of the comprehensive care plan dated 01/26/23 revealed Resident #34 had incontinence of bowel
and bladder with a goal to have no skin breakdown related to moisture and incontinence. Interventions
included protective and preventive skin care, monitoring incontinence and to provide assistance as needed
for incontinence care every two to three hours around the clock.
Review of the care plan updated 04/18/23 revealed Resident #34 had a stage II pressure ulcer to the
sacrum, with a goal to have no complications related to altered skin integrity. Interventions included
treatments as ordered, two assist for turning and repositioning to occur every two hours and as needed,
incontinence management, pressure reducing device for chair and mattress, and weekly skin assessments.
Review of the skin risk assessments from 01/18/23 to 04/11/23 revealed Resident #24 was a risk for skin
breakdown due to limited mobility and occasional moisture. The skin assessment on 04/13/23 revealed
Resident #34 had redness to the coccyx and was at high risk for skin breakdown due to very limited
mobility, inadequate nutrition, and very moist skin condition. A skin assessment dated [DATE] revealed the
reddened area on the coccyx was now open, with a measurement of 5.5 centimeters (cm) long by 3.5 cm
wide by 0 depth. On 04/25/23, Resident #34 had a stage II pressure ulcer 2.5 cm long by 1.8 cm wide by
0.1 cm deep to the sacrum, a stage II pressure ulcer on the right buttock, 3.2 cm long by 1.8 cm wide by
0.1 cm deep, and a stage II pressure ulcer on the left buttock with measurements of 2.2 cm long, by 1.2 cm
wide by 0.1 cm deep.
Review of the physician orders for Resident #34 revealed an order dated 04/17/23 for an air mattress and
orders written on 04/25/23 for the sacrum and left and right buttock to be washed with warm soap and
water, dry, apply hydrophilic wound cream and foam dressing every Tuesday, Friday, and as needed.
Observation on 04/24/23 at 3:26 P.M. of Resident #34 lying in bed on the right side, with an air mattress
pump set at 180 millimeters of mercury (mmHG). The pump flashed between two lights, a red
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365510
If continuation sheet
Page 7 of 10
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
365510
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bethesda Care Center
600 N Brush St
Fremont, OH 43420
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 0686
light (low pressure) and green light (normal pressure).
Level of Harm - Minimal harm
or potential for actual harm
Observation on 04/25/23 at 10:45 A.M. of Resident #34 lying on their back in bed with the air mattress
pump lights flashing between red (low pressure) and green (normal pressure).
Residents Affected - Few
Observation of wound care on 04/25/23 at 10:49 A.M. for Resident #34 completed by Registered Nurse
(RN) #418, with the assistance of State Tested Nursing Assistant (STNA) #483, revealed three
non-blanchable areas surrounded by redness on the sacrum, right buttock, and left buttock of Resident
#34. The wounds were cleansed with soap and water, dried, hydrophilic wound cream applied followed by a
foam dressing. Resident #34 was positioned onto the right side with two pillows.
Interview on 04/25/23 at 10:55 A.M. with RN #418 verified the air mattress pump lights flashed between red
and green. RN #418 stated she was unfamiliar with the pump, did not know what the alternating red and
green meant.
Observation on 04/25/23 at 2:44 P.M. of Resident #43 revealed the resident was in bed on the right side
with head of bed elevated, the air mattress pump lights flashed between red and green.
Interview on 04/25/23 at 2:46 P.M. with STNA #483 verified Resident #34 remained on the right side and
STNA #483 revealed the resident had not been repositioned since 10:49 A.M. STNA #483 was unaware of
what the alternating red and green lights on the air mattress pump indicated.
Observations on 04/26/23 at 7:40 A.M. and 11:40 A.M. revealed the air mattress pump continued to flash
between the red and green lights.
Review of the facility policy titled, Quality of Care, dated 11/28/16 stated residents are provided the
assistance required to attain and or maintain the highest practicable level of function.
Review of the air mattress with digital pump procedure manual revealed the red light is a low pressure
indicator when the air pressure is below the present level. The green light indicates the pump is functioning
correctly and the present level of pressure is provided.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365510
If continuation sheet
Page 8 of 10
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
365510
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bethesda Care Center
600 N Brush St
Fremont, OH 43420
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, resident interview, staff interview and review of facility policy, the facility
failed to ensure oxygen supplies were dated when initiated according to physician orders. This affected one
resident (#42) of five residents reviewed for oxygen therapy. The facility census was 63.
Residents Affected - Few
Findings include:
Review of Resident #42's medical record revealed an admission date of 06/01/22. Diagnoses included
congestive heart failure (CHF), type II diabetes, morbid obesity, osteoarthritis, anxiety disorder, major
depressive disorder, hypertension.
Review of Resident #42's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #42 was
cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Resident #42 required
extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #42 received
oxygen therapy at the time of the review.
Review of Resident #42's care plan revised 03/12/23 revealed supports and interventions for need for
hospice services, self-care deficit, and respiratory diagnosis. Interventions for respiratory diagnosis
included administer oxygen as ordered.
Review of Resident #42's physician orders revealed an order dated 06/02/22 for Resident #42 to have
oxygen at four liters continuously.
An order dated 06/02/22 to change Resident #42's oxygen tubing, humidifier, wash filters on concentrator
weekly and date and initial each piece on change. To be completed every Sunday.
Observation on 04/24/23 at 10:19 A.M. found Resident #42's oxygen tubing and humidifier was not dated
as to when it was changed. Coinciding interview with Resident #42 revealed the staff did not always change
her humidifier when it was needed. She stated she ended up not breathing well because the water runs out
and she needs the humidifier.
Observation on 04/26/23 at 3:10 P.M. of Resident #42's oxygen tubing and humidifier found there continued
to be no date.
Observation on 04/27/23 at 9:12 A.M. of Resident #42's oxygen tubing and humidifier found there continued
to be no date indicating when they were last changed. Coinciding interview with Resident #42 revealed she
was aware her humidifier water was getting low and had not been changed. Resident #42 reported with her
oxygen running at four liters continuously the humidifier needed to be changed twice a week or it ran out.
Resident #42 reported the staff told her yesterday it was going to need to be changed soon. Observation of
the humidifier found a very small amount of fluid in the bottom of the humidifier.
Interview on 04/27/23 at 9:13 A.M. with Registered Nurse (RN) #418 verified Resident #42 oxygen tubing
and humidifier had not been dated and the water level in the humidifier was close to empty. RN #418 stated
she would get the supplies and replace and date both the tubing and the humidifier today.
Review of the facility policy titled, Oxygen Administration, revised 11/28/22 revealed the facility
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365510
If continuation sheet
Page 9 of 10
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
365510
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/27/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bethesda Care Center
600 N Brush St
Fremont, OH 43420
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 0695
staff was to verify the practitioner's order for oxygen therapy and documented the procedure completed.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365510
If continuation sheet
Page 10 of 10
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
20 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.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0346GeneralS&S Fpotential for harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0354GeneralS&S Fpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Fpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the April 27, 2023 survey of BETHESDA CARE CENTER?
This was a inspection survey of BETHESDA CARE CENTER on April 27, 2023. The surveyor cited 20 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BETHESDA CARE CENTER on April 27, 2023?
Yes, 20 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
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.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.