Bethesda Care Center: Advance Directive Ignored - OH
The facility ignored that for two months.
The resident, identified in inspection records only as Resident 40, was admitted to Bethesda Care Center on July 23, 2025. Her diagnoses filled more than a paragraph of the inspection report: sepsis, a bloodstream infection tied to a central venous catheter, cellulitis of the left lower limb, chronic lymphocytic leukemia, stage three chronic kidney disease, dependence on renal dialysis, acute kidney failure, peripheral vascular disease, chronic ischemic heart disease, pneumonia, morbid obesity, type two diabetes, and more than a dozen other conditions. She was, by any measure, gravely ill.
She was also cognitively intact. A mental status assessment conducted in late August scored her at 15 out of 15, the highest possible mark. She understood her situation. She had made her wishes clear in writing.
The advance directive she signed, dated June 20, 2025, designated her as DNR Comfort Care-Arrest. Under that designation, staff treat a resident normally up to the moment of cardiac or respiratory arrest, at which point all interventions stop and comfort care begins. It is a specific, deliberate choice, and she had made it more than a month before she ever set foot in the building.
The physician order entered on her admission date said full code. Every resuscitation procedure available would be provided if she arrested. The order contradicted her directive completely, and it stayed that way.
Nobody caught it in July. Nobody caught it in August. The order sat in her medical record, pointing in the opposite direction from her signed wishes, through the summer and into the fall.
On September 23, 2025, two days before state inspectors arrived at the facility, the order was finally changed to match what she had asked for. The inspection report does not explain what prompted the correction, or whether anyone at the facility had noticed the discrepancy before then.
The Director of Nursing confirmed the timeline during an interview with inspectors the following morning. She verified that the advance directive existed and was dated June 20. She verified the full-code order had been in place from July 23 through September 23. She verified the change was made on September 23. The inspection report records her confirmation without elaboration.
The violation was cited under a complaint, logged as Complaint Number 2607054, meaning someone had contacted regulators about conditions at the facility before inspectors ever scheduled their visit.
CMS rated the harm level as minimal, a designation that applies when a deficiency creates the potential for harm but no documented injury has occurred. In this case, that means inspectors found no record that Resident 40 experienced a cardiac or respiratory arrest during the two months her code status was wrong. She was not resuscitated against her will, as far as the record shows. The harm was potential, not actual.
But potential is not nothing when the patient is someone on dialysis with leukemia and a history of sepsis and heart disease. An arrest was not an abstract possibility for her. It was a foreseeable event, the exact event her advance directive was written to address. For sixty-two days, the plan in place was the one she had specifically said she did not want.
Advance directives exist because patients learned, over decades of medical history, that their wishes would be overridden without them. The paperwork was created to prevent exactly this. A person decides, while competent, what should happen to their body at the worst moment. They sign the form. The form goes into the record. The record is supposed to drive the orders.
At Bethesda Care Center, it didn't.
The facility's own policy, reviewed by inspectors, stated that advance directives would be respected and that each resident's plan of care would be consistent with their documented treatment preferences. The policy said the right things. The practice, for Resident 40, did not match them.
Three residents were reviewed for code status during this inspection. The violation applied to one. The report does not describe what was found for the other two, which means their records either matched their directives or were not flagged.
Bethesda Care Center sits on North Brush Street in Fremont, a city of roughly 16,000 in Sandusky County. The facility had 75 residents at the time of the inspection.
Resident 40 needed help with every functional task, the inspection records note. She required at least some assistance for all activities of daily living. She was dependent on dialysis to keep her kidneys functioning. She was fighting leukemia. She had already navigated enough of the medical system to know she wanted to make her own decisions about the end of her life, and she had done the work to document those decisions formally, in advance, before she arrived.
For two months, the order in her chart said otherwise.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bethesda Care Center from 2025-09-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 13, 2026 · Our methodology
BETHESDA CARE CENTER in FREMONT, OH was cited for violations during a health inspection on September 25, 2025.
The facility ignored that for two months.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.