Bethesda Care Center: DNR Order Ignored in Care Plan - OH
The resident, identified in inspection records only as Resident #40, was admitted to the 75-bed facility with one of the longest diagnosis lists inspectors documented: sepsis, cellulitis of the left lower leg, chronic lymphocytic leukemia, stage three chronic kidney disease, dependence on renal dialysis, peripheral vascular disease, acute kidney failure, chronic ischemic heart disease, and more than two dozen other conditions. A cognitive assessment scored the resident at 15 out of 15, meaning fully intact. Whatever decision Resident #40 made about end-of-life care, they made it with a clear mind.
That decision was Do Not Resuscitate Comfort Care-Arrest, a specific designation meaning staff treat the person like any other patient right up until cardiac or respiratory arrest, at which point all interventions stop and comfort care begins. The resident signed an Advanced Directives form to that effect. A physician order reflected the same status.
The care plan said something else entirely.
Inspectors reviewing the most recent care plan found interventions stating that if cardiac or pulmonary arrest occurred, the resident would receive artificial resuscitation. Full CPR would be performed by staff. Interventions listed included providing full resuscitative measures and initiating 911.
The Director of Nursing, interviewed at 7:28 in the morning on the day of the inspection, confirmed all of it. She verified the signed Advanced Directives form existed. She verified the physician order for DNR CC-A was in the record. She verified the care plan directed staff to run a full code.
Nobody had caught it. Nobody had corrected it.
The inspection was triggered by a complaint, logged under complaint number 2607054. Inspectors reviewed three residents' records for care planning of code status. The problem appeared in one of them.
What the care plan error means in practice is not theoretical. Nursing home staff responding to a cardiac arrest in the middle of the night do not pause to cross-reference physician orders against a resident's signed directives. They go to the care plan. The care plan is the operational document, the one that tells a nurse or aide what to do when something goes wrong and there is no time to deliberate. For Resident #40, that document would have sent staff in the opposite direction from what the resident chose.
The facility's own advance directives policy, reviewed during the inspection, stated that the plan of care for each resident will be consistent with their documented treatment preferences and advance directives. The care plan for Resident #40 was not.
CMS rated the deficiency as minimal harm or potential for actual harm, the lower end of the harm scale. That rating reflects what inspectors found on the day they arrived, not what might have happened on any other day. Resident #40, by the time inspectors reviewed the record, had not experienced a cardiac or pulmonary arrest. The mismatch between the DNR order and the care plan had not yet cost them anything.
Whether Resident #40 or their family knew the care plan contradicted their wishes, the inspection report does not say.
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.
A cognitive assessment scored the resident at 15 out of 15, meaning fully intact.
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.