Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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.
Failure to document informed consent for psychotropic meds: Staff notified residents’ representatives of psychotropic med changes, but records did not show that the indication, risks vs benefits, or alternative treatments were explained before Seroquel, Olanzapine, trazodone, quetiapine, or Celexa were started or changed. The RN manager/IP C said consent was obtained verbally and notes recorded notifications, but the EMRs lacked specific documentation of informed consent or written consent for the med changes.
The facility failed to accurately code MDS assessments for two residents. One resident with Alzheimer’s disease, major depression, anxiety, and a psychotic disorder had MDSs that did not indicate a Level II PASRR despite prior PASRR approval for an unlimited LTC stay, and the MDS coordinator acknowledged the error. Another resident admitted with PTSD had an admission MDS that did not mark PTSD as an active diagnosis, and the MDS coordinator acknowledged the diagnosis was present on admission and that psychiatric services had been provided.
A resident with COPD and a history of thrush received budesonide nebulizer treatments, but staff did not consistently rinse the nebulizer mask or instruct him to rinse his mouth after treatments. The resident reported that nurses or CMAs often left the room during treatments and that he was not told to rinse afterward, while the EMR showed budesonide orders that specifically instructed mouth rinsing to help prevent oral thrush. Staff interviews and the manufacturer's instructions showed the nebulizer chamber and face mask were to be cleaned after each use, but practice at the facility did not consistently follow those directions.
A fentanyl patch for a resident was removed from a double-locked controlled substance drawer and then went missing before it was securely administered or accounted for. Surveyors also found another resident’s bedside medications and personal care products left unsecured in the room, opened latanoprost eye drops without dates for two residents, expired insulin syringes in medication carts and a med room, and pre-prepared meds left in a locked cart rather than being immediately administered.
The facility failed to ensure residents' privacy by not obtaining consent for audio and video monitoring devices in their rooms. Six residents had devices capable of monitoring without proper signage or staff awareness. The facility's policies were inconsistent with practices, and informed consent was not obtained, violating residents' rights.
The facility failed to implement an effective grievance process, as evidenced by unresolved grievances from two residents. One resident expressed concerns about the dining room environment and dietary preferences, which were not consistently addressed. The resident council president reported a lack of follow-up on complaints, and staff interviews revealed gaps in the grievance process. The facility's grievance policy was not effectively implemented, leading to unresolved issues and resident dissatisfaction.
The facility failed to ensure prompt responses to call lights, impacting residents' well-being. Residents reported waiting up to 45 minutes for assistance, particularly in the mornings. Call light logs confirmed these delays, with multiple instances of waits over 30 minutes. The facility was experiencing a COVID-19 outbreak, which may have contributed to the issue. Despite staff consensus on prompt response times, residents experienced incontinence accidents due to delays. The facility's call light policy was not effectively monitored, leading to documented deficiencies.
Failure to Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents or their representatives were fully informed of the risks versus benefits of psychotropic medications and alternative treatments before those medications were administered. Review of records, interviews, and policy showed that staff notified representatives of medication changes for residents with impaired cognition, but the documentation did not show that the indication for the medication, the risks and benefits, or alternative treatments were explained before psychotropic medications were started or changed. For one resident with Alzheimer’s disease, major depression, anxiety, and a psychotic disorder with delusions, the psychiatric provider changed Seroquel orders for psychosis and physically aggressive behaviors and added a PRN dose. The nurse’s note showed the representative was notified of the new orders, but there was no documentation that the resident or representative was informed of the reason for the medication change, the risks versus benefits, or alternative treatments. For another resident with neurocognitive disorder with Lewy bodies, hallucinations, dementia, and PTSD, an order for Olanzapine was entered, but there was no documentation that staff provided information to the resident or representative regarding the psychotropic medication. For a third resident with severe cognitive impairment, dementia with agitation, and insomnia, multiple psychotropic medication changes occurred, including trazodone, quetiapine, and Celexa. The record showed phone notifications to the representative and some discussion of psychiatry services and medication changes, but it did not show informed consent, written consent, or documentation that risks versus benefits were explained for the new medications or dosage changes. The RN manager/IP C stated that the facility obtained verbal consent and documented notifications, but the notes did not include specific details about risk-versus-benefit information, and the administrator acknowledged the facility did not use a written informed consent form for psychotropic medications.
MDS Coding Errors for PASRR and Active Diagnosis
Penalty
Summary
The facility failed to ensure accurate MDS coding for PASRR for one resident and for active diagnoses for another resident. One resident, admitted with diagnoses including Alzheimer's disease, major depression, anxiety, and a psychotic disorder with delusions, had a comprehensive admission MDS and a later comprehensive MDS that did not mark A1500 as yes for a Level II PASRR, even though prior PASRR documentation showed a Level II determination approving an unlimited long-term care stay. During interview, the MDS coordinator acknowledged that the resident did have a mental health diagnosis of major depressive disorder and that she had made a mistake by indicating he did not have a Level II PASRR. A second resident, admitted with PTSD, had an admission MDS that did not mark I6100 Post Traumatic Stress Disorder under psychiatric/mood disorder in section I. During interview, the MDS coordinator acknowledged the resident had PTSD on admission and had received psychiatric services before admission and again after admission with a new provider. She stated she relied on the information sent with the resident, including diagnoses, medication orders, and physician progress notes, but did not consider PTSD an active diagnosis because the resident did not have medications prescribed for it.
Failure to Follow Budesonide Nebulizer Instructions
Penalty
Summary
The nursing facility failed to ensure that budesonide nebulizer treatments were administered according to the manufacturer's instructions for one resident who had COPD and a history of thrush. Observation of the resident's room showed a nebulizer machine and mask on the bedside table, with the mask assembled and sitting on the machine. During interview, the resident stated that nurses or CMAs gave him nebulizer treatments twice daily, often left the room while he was receiving them, and sometimes returned to rinse the nebulizer mask but sometimes did not. He also stated that staff did not tell him to rinse his mouth after treatments, and he did not know he was supposed to do so. The medication chamber appeared hazy with an unknown substance, and the resident said he sometimes took a lozenge to treat thrush because one of his nebulizer medications caused it. The resident's EMR showed a physician's order for budesonide nebulizer twice daily with instructions to make sure the mouth was rinsed with water after treatment to help prevent oral thrush, and a prior order for clotrimazole troches for thrush. The record also documented that the resident had requested additional clotrimazole because he felt he had oral thrush and reported having had it before. Staff interviews showed differing practices: one RN stated she remained in the room during nebulizer treatments, shook out excess liquid, and placed the mask in a vented storage bag to dry, while the DON stated she expected the mask to be rinsed and was not aware the budesonide manufacturer's instructions required washing the nebulizer chamber and face mask with mild detergent after each administration. The provider's nebulizer policy addressed discarding excess solution and using a vented storage bag, but the manufacturer's instructions required rinsing the mouth after each nebulization and cleaning the nebulizer chamber and mask after every administration.
Medication storage, labeling, and disposal failures
Penalty
Summary
Drugs and biologicals were not consistently labeled, securely stored, or discarded in accordance with facility policy and accepted medication storage practices. A fentanyl patch for resident 35 was removed from the double-locked controlled substance drawer by RN K, but it was not immediately administered or securely maintained. RN K placed the patch on top of a Tegaderm package, carried multiple items into the resident’s room, and later discovered the patch was missing. She searched the resident’s room, the hallway, the medication cart, her shoes, and garbage bags, and additional staff searched laundry, housekeeping areas, and the vacuum, but the patch was not found. The controlled drug record later documented one patch as missing and another as wasted, and the report states the missing patch could not be witnessed as wasted because it was not located. Resident 24 had several medications and personal care products in his room, including Vicks Vaporub, Gold Bond medicated powder, Blu-Emu cream, Voltaren 1% cream, and seawater nasal spray. Observation and interview showed these items were left on tables in the resident’s room rather than being securely stored. Resident 24 stated he used the products as needed and that they were left in his room for him to use. His record showed orders allowing bedside use for some medications and a self-administration assessment indicating he could safely administer pills, creams, and ointments with setup, but the assessment also stated the self-administered medications were stored in the nursing medication cart. The facility also failed to label and discard medications with shortened expiration dates and failed to remove expired supplies from active use. Latanoprost eye drops for residents 13 and 18 were observed without a date showing when they were opened, and staff stated they did not routinely date eye drops when opened. Expired 100-unit insulin syringes were found in the medication room and in all three observed medication carts. In addition, RN G described preparing resident 6’s medication ahead of administration and placing it in a labeled medication cup in the locked medication cart until the resident returned, and RN manager/IP C observed stacked medication cups with a medication between them in medication cart C. The facility policy required medications with shortened expiration dates to be labeled upon opening, medications to be stored in locked compartments when not in use, and controlled substances to be kept in separately locked compartments.
Failure to Ensure Privacy with Audio/Video Monitoring Devices
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records by not obtaining consent for the use of audio and video monitoring devices in residents' rooms. Six residents were identified as having such devices, which included [NAME] Echo devices and iPads, capable of video and audio monitoring. Observations revealed that these devices were active in residents' rooms without any signage indicating their presence, and staff members were largely unaware of the devices' capabilities to monitor audio and video. Interviews with staff, including a CNA, RN, and LPN, indicated a lack of awareness regarding the monitoring capabilities of the devices. The LPN acknowledged that some devices could allow external parties to listen in on residents' rooms. The Director of Nursing (DON) admitted that the devices were introduced recently and were primarily used for psychosocial reasons, such as playing music, but was unaware of their full monitoring capabilities. The facility had not obtained informed consent from residents for the use of these devices. The facility's policies were inconsistent with the practice observed. The provider's policy from December 2024 stated that video and audio monitoring were not allowed in resident rooms, yet devices capable of such monitoring were present. A new policy regarding [NAME] devices was developed only after the survey, indicating a lack of prior protocol. The South Dakota State Long-Term Care Ombudsman Program's resident rights handbook requires consent and signage for video monitoring, which the facility failed to implement.
Ineffective Grievance Process in LTC Facility
Penalty
Summary
The facility failed to implement an effective grievance process for residents, as evidenced by the lack of documentation, investigation, and follow-up on grievances reported by two residents. Resident 32, who had been living in the facility for nearly three years, expressed concerns about the dining room being cold, the cleanliness of the air exhaust vent, and the accuracy of the menu board. Additionally, she had specific dietary preferences due to her diabetes and personal dislikes, which were not consistently honored. Despite discussing these issues with staff, no actions were taken to address her grievances, and there was no documentation of these concerns in the grievance records. Resident 10, the president of the resident council, also reported issues with the grievance process. She was unaware of how complaints from the resident council were addressed and had not seen any concern forms. The resident council meetings, coordinated by Activity Director F, lacked proper documentation and follow-up on concerns raised by residents. The minutes did not reflect resolutions to previous issues, and there was no written communication regarding the concerns discussed during the meetings. Interviews with staff, including the Licensed Social Worker (LSW) H and Director of Nursing (DON) B, revealed gaps in the grievance process. LSW H, who was responsible for handling grievances, admitted to not being aware of the difference between a complaint and a grievance according to the facility's policy. Furthermore, there was no Grievance Committee in place, and grievances were not reviewed during Quality Assurance meetings. The facility's grievance policy outlined the need for a formal process, but this was not effectively implemented, leading to unresolved grievances and dissatisfaction among residents.
Delayed Call Light Responses in LTC Facility
Penalty
Summary
The facility failed to maintain the physical, mental, and psychosocial well-being of residents by not ensuring prompt responses to call lights. Interviews with residents revealed that they experienced significant delays in receiving assistance after activating their call lights. For instance, one resident reported waiting up to 45 minutes for help, particularly in the mornings when she needed assistance with dressing. Another resident expressed similar concerns about long wait times, which he planned to address in an upcoming care conference. The review of call light logs confirmed these delays, showing multiple instances where residents waited over 30 minutes for assistance. The facility was experiencing a COVID-19 outbreak, which the MDS coordinator suggested might have contributed to the extended wait times. However, the Director of Nursing (DON) was unaware of any reports of long wait times and acknowledged that the recorded wait times were unacceptable. The facility's call light policy emphasized the importance of promptly answering call lights, yet there were no audits conducted to monitor compliance with this policy. Interviews with staff, including LPNs and RNs, indicated a consensus that call lights should be answered within five to fifteen minutes. Despite this, residents reported incidents where they were left waiting for extended periods, leading to incontinence accidents. The facility's grievance records also highlighted past issues with delayed responses to call lights, including a resident being left on a commode for two hours. The facility's staffing model aimed to promote resident quality of life, but the current practices did not align with this goal, as evidenced by the documented deficiencies in call light response times.
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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 Webster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sun Dial Manor | 10.6 mi | ★★★★★ | 1 | 0 |
| Strand-kjorsvig Community Rest Home | 10.8 mi | ★★★★★ | 0 | 0 |
| Avantara Groton | 28.6 mi | ★★★★★ | 11 | 0 |
| Tekakwitha Living Center | 32.5 mi | ★★★★★ | 15 | 0 |
| Wilmot Care Center Inc | 33 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.