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BETHESDA HEALTH AND REHABILITATION

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BETHESDA HEALTH AND REHABILITATION VS
Nursing Homes USA
General
City BETHESDA   0% Nursing Homes USA have BETHESDA
State attribute explanation MD   1.5% Nursing Homes USA have MD
Street 5721 GROSVENOR LANE  
Zip Code 20814  
Phone 3015301600  
Overall Star Rating
3.11
Health Inspections Star Rating
2.83
Nurse Staffing Star Rating
3.17
Quality Measures Star Rating
3.31
RN Only Star Rating
3.17
Number of Certified Beds
200 
108.94
Total Number of Residents
169 
91.25
Percent of Occupied Beds
85 %
83.65 %
Health Survey Date 5/8/2012  
Fire Survey Date 5/8/2012  
Sprinkler Status Fully Sprinklered  90.2% Nursing Homes USA have Fully Sprinklered
Program Participation Medicare And Medicaid  91.5% Nursing Homes USA have Medicare and Medicaid
Type of Ownership For Profit - Corporation  56.7% Nursing Homes USA have For profit - Corporation
Located Within a Hospital? No  93.6% Nursing Homes USA don't have Located Within a Hospital?
Multi Nursing Home Ownership? Yes  54.9% Nursing Homes USA have Multi Nursing Home Ownership?
Resident and Family Councils RESIDENT   66% Nursing Homes USA have RESIDENT
Continuing Care Retirement Community? No  90.9% Nursing Homes USA don't have Continuing Care Retirement Community?
Quality Indicator Survey? Yes  31.3% Nursing Homes USA have Quality Indicator Survey?
Special Focus Facility? No  99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count
75.2 
58.16
Total Enforcement Actions Count
75.2 
56.31
# of deficiencies
24 
7.48
Staff Information
Number of Residents
169 
91.38
Number of RN Hours Per Resident Per Day
0.63 
0.77
Number of LPN/LVN Hours Per Resident Per Day
1.28 
0.84
Total Number of Licensed Staff Hours Per Resident Per Day
1.91 
1.59
Number of CNA Hours Per Resident Per Day
0.17 
5.49
Number Therapy Hours Per Resident Per Day
0.17 
0.10
Environmental Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 04/12/2010
date Of Correction: 06/10/2010 
Mistreatment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: 1) Hire Only People With No Legal History Of Abusing, Neglecting Or Mistreating Residents; Or 2) Report And Investigate Any Acts Or Reports Of Abuse, Neglect Or Mistreatment Of Residents.
survey Date: 01/17/2012
date Of Correction: 03/02/2012 
Resident Rights Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 1
deficiency: Give Notice To The Resident Before A Room Or Roommate Change.
survey Date: 04/14/2011
date Of Correction: 04/15/2011 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 04/14/2011
date Of Correction: 04/15/2011 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 04/12/2010
date Of Correction: 06/10/2010 
Quality Care Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 1
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 02/10/2012
date Of Correction: 03/15/2012 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 04/14/2011
date Of Correction: 04/15/2011 
Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 04/14/2011
date Of Correction: 04/15/2011 
Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.
survey Date: 04/12/2010
date Of Correction: 06/10/2010 
Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 04/12/2010
date Of Correction: 06/10/2010 
Deficiency #6 Scope: Some
level Of Harm: 2
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 04/12/2010
date Of Correction: 06/10/2010 
Resident Assessment Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured.
survey Date: 01/17/2012
date Of Correction: 03/02/2012 
Deficiency #2 Scope: Some
level Of Harm: 1
deficiency: Allow The Resident The Right To Participate In The Planning Or Revision Of The Resident's Care Plan.
survey Date: 04/14/2011
date Of Correction: 04/15/2011 
Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured.
survey Date: 04/14/2011
date Of Correction: 04/15/2011 
Deficiency #4 Scope: Some
level Of Harm: 2
deficiency: Conduct Initial And Periodic Assessments Of Each Resident's Functional Capacity.
survey Date: 04/14/2011
date Of Correction: 04/15/2011 
Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured.
survey Date: 04/12/2010
date Of Correction: 06/10/2010 
Administration Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 1
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 04/14/2011
date Of Correction: 04/15/2011 
Pharmacy Service Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Maintain Drug Records And Properly Mark/label Drugs And Other Similar Products According To Accepted Professional Standards.
survey Date: 04/14/2011
date Of Correction: 04/15/2011 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: At Least Once A Month, Have A Licensed Pharmacist Review Each Resident's Medication(s) And Report Any Irregularities To The Attending Doctor.
survey Date: 04/14/2011
date Of Correction: 04/15/2011 
Deficiency #3 Scope: Some
level Of Harm: 1
deficiency: 1) Make Sure That Each Resident's Drug Regimen Is Free From Unnecessary Drugs; 2) Each Resident's Entire Drug/medication Is Managed And Monitored To Achieve Highest Well Being.
survey Date: 04/14/2011
date Of Correction: 04/15/2011 
Deficiency #4 Scope: Some
level Of Harm: 2
deficiency: 1) Make Sure That Each Resident's Drug Regimen Is Free From Unnecessary Drugs; 2) Each Resident's Entire Drug/medication Is Managed And Monitored To Achieve Highest Well Being.
survey Date: 04/12/2010
date Of Correction: 06/10/2010 
Deficiency #5 Scope: Some
level Of Harm: 1
deficiency: Maintain Drug Records And Properly Mark/label Drugs And Other Similar Products According To Accepted Professional Standards.
survey Date: 08/10/2009
date Of Correction: 09/29/2009 
Deficiency #6 Scope: Few
level Of Harm: 2
deficiency: Make Sure That Residents Are Safe From Serious Medication Errors.
survey Date: 08/10/2009
date Of Correction: 09/29/2009 
Nutrition and Dietary Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 1
deficiency: Store, Cook, And Serve Food In A Safe And Clean Way.
survey Date: 04/14/2011
date Of Correction: 04/15/2011 
Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
16.7 %
25.09 %
Percent of long-stay residents whose need for help with daily activities has increased
75.2 %
32.95 %
Percent of long-stay residents who self-report moderate to severe pain
6 %
16.66 %
Percent of long-stay high-risk residents with pressure ulcers 11.8:1 % 
Percent of long-stay residents who lose too much weight
3.5 %
11.83 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
54.3 %
44.54 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
2 %
15.63 %
Percent of long-stay residents with a urinary tract infection 5.6:1 % 
Percent of long-stay residents who have depressive symptoms
75.2 %
28.38 %
Percent of long-stay residents who were physically restrained
75.2 %
43.68 %
Percent of short-stay residents who self-report moderate to severe pain
29.5 %
25.02 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
96.2 %
84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
98.5 %
83.94 %
Percent of short-stay residents who newly received an antipsychotic medication
75.2 %
45.90 %
Percent of long-stay residents experiencing one or more falls with major injury
2.1 %
15.52 %
Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
17.6 %
25.39 %
Percent of long-stay residents whose need for help with daily activities has increased
75.2 %
23.70 %
Percent of long-stay residents who self-report moderate to severe pain
6.2 %
14.10 %
Percent of long-stay high-risk residents with pressure ulcers
10.2 %
9.22 %
Percent of long-stay residents who lose too much weight
4.3 %
8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
47.5 %
43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
1.3 %
10.65 %
Percent of long-stay residents with a urinary tract infection
6.5 %
9.58 %
Percent of long-stay residents who have depressive symptoms
0.7 %
19.86 %
Percent of long-stay residents who were physically restrained
75.2 %
38.53 %
Percent of long-stay residents experiencing one or more falls with major injury
2.4 %
10.73 %
Percent of short-stay residents who self-report moderate to severe pain
22.8 %
24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
92.9 %
81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
96.9 %
74.75 %
Percent of short-stay residents who newly received an antipsychotic medication
75.2 %
17.34 %

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