Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethesda Home during CMS and state inspections, most recent first.
The facility failed to schedule an RN for eight consecutive hours a day, seven days a week, for 86 days in 2024. Interviews and record reviews confirmed the absence of RN coverage, which is crucial for emergency assessments and medication management. The Administrator acknowledged the deficiency, which was documented in the PBJ Staffing Data Reports.
The facility failed to conduct annual performance evaluations for four CNAs and one CNAL, as required by their policy. The evaluations were overdue, with the last ones conducted between April 2023 and November 2022. This oversight was confirmed through interviews and record reviews, highlighting a potential risk for unsafe and incompetent resident care.
The facility failed to replace an oral emergency medication kit within 72 hours after use and had an injectable kit with 15 expired medications. An LVN confirmed the oral kit was not replaced despite notifying the pharmacy, and the injectable kit was rarely used but contained expired meds. The Pharmacy Consultant and MDS Coordinator acknowledged the deficiencies, noting that the kits should be replenished and checked for expiration as per facility policy.
A facility failed to maintain a medication error rate below five percent, resulting in a 6.06 percent error rate. Errors included an LVN crushing an extended-release Mirabegron tablet for a resident, against manufacturer instructions, and improperly administering Timolol maleate eye drops to another resident by not instructing them to close their eyes for proper distribution. These actions deviated from the facility's policies and standard practices.
The facility failed to employ a full-time Dietary Manager (DM) while having a part-time Registered Dietician (RD), risking inadequate nutrition for 32 residents. The DM worked about 30 hours weekly, and the RD worked on-site monthly. The Administrator lacked documentation for the RD's schedule and a policy for a full-time DM, violating California Health and Safety Code.
The facility failed to maintain sanitary conditions in food storage and preparation, with unlabeled and unsealed food items found in the freezer and refrigerator, food stored less than six inches from the floor, and a staff member not wearing a beard restraint during meal preparation. These actions violated the facility's policies and posed a risk of foodborne illnesses to residents.
A facility failed to follow infection control practices during medication administration for three residents. An LVN did not sanitize a reusable medication tray between uses and neglected hand hygiene after retrieving medication from a refrigerator. These actions were against the facility's policies, which required equipment disinfection and hand hygiene to prevent infection transmission.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to schedule a registered nurse (RN) for eight consecutive hours a day, seven days a week, for a total of 86 days in 2024. This deficiency was identified through interviews and record reviews. The Minimum Data Set Coordinator (MDSC) confirmed that there were multiple days when the facility did not have an RN on duty for the required hours. The Director of Staffing Development (DSD) emphasized the importance of having an RN available for emergency assessments, initial resident assessments, intravenous medications, and medication destruction. The Administrator (ADM) acknowledged the absence of RN coverage for the required hours on several days, as indicated in the Payroll-Based Journal (PBJ) Staffing Data Reports for Fiscal Year Quarters 2 and 3 of 2024. The facility's policy, revised in August 2022, mandates that a registered nurse provides services for at least eight consecutive hours every 24 hours, seven days a week. Despite this policy, the facility failed to meet the staffing requirements, potentially placing residents at risk of receiving insufficient care.
Failure to Conduct Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that four Certified Nursing Assistants (CNAs) and one Certified Nursing Assistant Lead (CNAL) had the appropriate competencies to care for residents due to the lack of completed Annual Performance Evaluations. This deficiency was identified during interviews and record reviews, where it was revealed that the CNAs and CNAL had not received their evaluations within the required annual timeframe. Specifically, CNA 1's last evaluation was in April 2023, CNA 2's in October 2023, CNA 3's in June 2023, CNA 4's in November 2022, and CNAL's in April 2023. The Director of Staffing Development (DSD) confirmed that these evaluations were overdue and emphasized their importance in ensuring the CNAs' ability to perform their required skills and tasks. The facility's policy and procedure on Performance Evaluations, which was undated, indicated that each employee's job performance should be reviewed and evaluated at least annually. However, the facility did not adhere to this policy, resulting in the potential for resident care to be provided in an unsafe and incompetent manner. The deficiency was highlighted during interviews with the CNAs and CNAL, who confirmed the dates of their last evaluations, and through the review of their personnel folders, which corroborated the overdue status of their evaluations.
Failure to Replace and Maintain Emergency Medication Kits
Penalty
Summary
The facility failed to ensure that medications were appropriately acquired, received, and dispensed, as evidenced by issues with two emergency medication kits (E-Kits). An oral E-Kit was not replaced within the required 72 hours after being opened, despite the facility notifying the pharmacy on the day it was used. The Licensed Vocational Nurse (LVN) confirmed that the oral E-Kit was opened and sealed with red plastic ties, indicating it had been used, and acknowledged that the pharmacy had not yet replaced it. Additionally, an injectable E-Kit contained 15 expired medications, with expiration dates ranging from April to September of the same year. The LVN admitted that the injectable E-Kit was rarely used and was unsure if the pharmacy had been contacted for replacement. Interviews with the Pharmacy Consultant and the Minimum Data Set Coordinator revealed acknowledgment of the deficiencies. The Pharmacy Consultant admitted to missing the expired E-Kit during an inspection and confirmed that the oral E-Kit should have been replaced within 72 hours. The Minimum Data Set Coordinator emphasized that the opened E-Kit should be replenished within 24 hours and that expired medications should not be present, regardless of usage frequency. The facility's policy and procedures indicated that emergency kits should be replaced within 72 hours and checked monthly for expiration, but these protocols were not followed, leading to the deficiencies.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 6.06 percent during a medication pass observation. Two medication errors were identified involving two residents. The first error involved the administration of Mirabegron, an extended-release medication for overactive bladder, to a resident. The Licensed Vocational Nurse (LVN) crushed the Mirabegron tablet and mixed it with other medications in applesauce, contrary to the manufacturer's instructions and the facility's policy, which state that extended-release tablets should not be crushed as they are designed to release medication slowly over time. The second error occurred during the administration of Timolol maleate eye drops to another resident. The LVN failed to instruct the resident to gently close their eyes after administering the drops, which is necessary for proper distribution of the medication. This was not in accordance with the facility's policy on the instillation of eye drops, which emphasizes the importance of allowing the medication to be evenly distributed by closing the eyelids gently. Both errors highlight a deviation from standard professional practice and the facility's policies, potentially affecting the therapeutic effectiveness of the medications administered.
Deficiency in Dietary Management Staffing
Penalty
Summary
The facility failed to employ a full-time Dietary Manager (DM) while having a part-time Registered Dietician (RD), which could lead to inadequate oversight of the kitchen and potentially place 32 residents at risk of receiving inadequate nutrition. The DM worked approximately 30 hours a week, and the RD worked on-site once a month for six to eight hours, consulting remotely as needed. Interviews with the DM and RD highlighted the importance of having a full-time DM to ensure kitchen staff adhered to sanitation rules and residents' dietary needs. The Administrator acknowledged the lack of documentation for the RD's work schedule and the absence of a policy requiring a full-time DM. The DM's responsibilities included kitchen staff scheduling, training, infection control, safety compliance, and overall kitchen management. The California Health and Safety Code requires a full-time dietetic services supervisor if a registered dietitian is employed less than full-time, which the facility did not comply with, leading to the identified deficiency.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain proper sanitary conditions in food storage and preparation areas, as observed during a survey. In the walk-in freezer, several food items, including Danish pastries, waffles, and pot roast, were found unsealed, open to air, and not labeled with dates. Additionally, the resident refrigerator contained unlabeled and undated food items, such as an unsealed jar with an unknown substance and an opened package of cheese. The kitchen dry storage had food items stored less than six inches from the floor, and an expired canned food item was available for resident use. Furthermore, a box of rotten bell peppers was found in the walk-in refrigerator. These conditions were acknowledged by the staff, who admitted that such practices could lead to foodborne illnesses. During meal preparation, a staff member was observed not wearing a beard restraint while preparing food, which is against the facility's policy. The facility's policies and procedures require that all food stored in refrigerators or freezers be covered, labeled, and dated, and that dry storage items be kept at least six inches off the floor. The policies also mandate that beards and mustaches be covered during meal preparation and service. The staff's failure to adhere to these policies and procedures posed a risk of cross-contamination and foodborne illnesses to the residents.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to adhere to infection control practices during medication administration for three residents. During a medication pass observation, a Licensed Vocational Nurse (LVN) did not sanitize the reusable medication tray between uses for different residents. Specifically, after administering medications to one resident, the LVN placed the medication tray on the sink, washed hands, and then continued to use the same tray for another resident without sanitizing it. This action was contrary to the facility's policy, which required the use of cavicide disinfectant spray to sanitize equipment between resident uses. Additionally, the LVN did not perform hand hygiene at a critical point during the medication pass for another resident. After retrieving medication from the medication room refrigerator, the LVN continued with the medication pass without sanitizing hands, which was against the facility's hand hygiene policy. The Infection Preventionist confirmed that staff were expected to follow infection control standards, including hand hygiene and equipment disinfection, to prevent infection transmission. The facility's policies clearly outlined the need for cleaning and disinfecting reusable items between residents and performing hand hygiene before handling medications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hayward
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Anthony Care Center | 0.1 mi | ★★★★★ | 0 | 0 |
| We Care Skilled Nursing Facility | 0.3 mi | ★★★★★ | 0 | 0 |
| Serenethos Care Center, Llc | 0.5 mi | ★★★★★ | 0 | 0 |
| Golden Harbor Healthcare Center | 0.6 mi | ★★★★★ | 60 | 0 |
| Morton Bakar Center | 0.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.