Cycle 1
Health 2024-10-25 · Fire 2024-10-25
7 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Hayward, CA
Bethesda Home
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
22427 Montgomery Street, Hayward, CA
(510) 538-8300
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
28
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1972-12-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
11,175
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 30.00% · Performance 100.00% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.56
Baseline 4.86 hours · Performance 4.09 hours · Measure score 3.56 · Achievement 3.56 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 2 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 1 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
1.6%
1.3 pts worse
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 3.1% · Q3 0.0% · Q4 2.8% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.8%
6.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
4.1%
2.4 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.3% · Q3 6.7% · Q4 13.3% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.3% |
13.7%
7.4 pts better
|
19.6%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 6.2% · Q3 3.2% · Q4 10.0% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.0% |
14.2%
7.2 pts better
|
16.7%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 14.3% · Q3 4.3% · Q4 4.5% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.2% |
11.0%
0.8 pts better
|
16.3%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.7% |
10.7%
6 pts worse
|
14.9%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 13.6% · Q3 17.4% · Q4 31.8% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
1.2%
2.5 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 8.6% · Q4 2.8% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.7% |
10.9%
7.2 pts better
|
19.8%
16.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.9% · Q4 8.2% · 4Q avg 3.7% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
4.7%
2.5 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.0% · Q4 4.2% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.9% |
94.0%
1.1 pts worse
|
81.7%
11.2 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 92.9% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-02 · Fire 2023-11-02
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-10-21 · Fire 2022-10-21
9 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-10-25
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-10-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-10-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-10-25
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-25
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-22
C · Minimal harm
2024-10-25
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-11-22
C · Minimal harm
2024-10-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-22
F · Potential for more than minimal harm
2023-11-02
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-11-29
F · Potential for more than minimal harm
2023-11-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-11-29
F · Potential for more than minimal harm
2023-11-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-11-29
F · Potential for more than minimal harm
2023-11-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-29
F · Potential for more than minimal harm
2023-11-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-29
D · Potential for more than minimal harm
2023-11-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-29
C · Minimal harm
2023-11-02
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-11-29
D · Potential for more than minimal harm
2022-10-21
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-10-21
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-10-21
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-10-21
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-10-21
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-10-21
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-10-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-10-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-10-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-25
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-25
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-25
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-25
F801 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-20
F · Potential for more than minimal harm
2023-11-02
F801 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-11-28
F · Potential for more than minimal harm
2023-11-02
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-11-28
F · Potential for more than minimal harm
2023-11-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-11-02
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-28
F · Potential for more than minimal harm
2022-10-21
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-11-17
F · Potential for more than minimal harm
2022-10-21
F801 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2022-11-17
F · Potential for more than minimal harm
2022-10-21
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2022-11-17
F · Potential for more than minimal harm
2022-10-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-17
E · Potential for more than minimal harm
2022-10-21
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-11-17
E · Potential for more than minimal harm
2022-10-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-17
D · Potential for more than minimal harm
2022-10-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-11-17
D · Potential for more than minimal harm
2022-10-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-11-17
D · Potential for more than minimal harm
2022-10-21
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-11-17
Penalties and ownership
What sits behind the stars
Ownership
Christian Retirement Center Of Northern California
5% Or Greater Direct Ownership Interest · Organization
Christian Retirement Center Of Northern California
Operational/Managerial Control · Organization
Ekpenyong, Lovian
Operational/Managerial Control · Individual
Ekpenyong, Lovian
Corporate Director · Individual
Harvey, Robyn
Corporate Director · Individual
Kelly, Christina
Operational/Managerial Control · Individual
Kelly, Christina
Corporate Officer · Individual
Ng, Andrew
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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St Anthony Care Center
Hayward, CA
5-star overall rating with 5-star inspections with $51,355 in total fines with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
We Care Skilled Nursing Facility
Hayward, CA
5-star overall rating with 4-star inspections with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Serenethos Care Center, LLC
Hayward, CA
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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