Bethesda Care Center
600 N Brush St, Fremont, OH 43420 · Sandusky County · 89 certified beds · avg 82 residents/day · certified since Jul 1, 1980
Part of chain: GARDEN SPRINGS HEALTHCARE (5 facilities, chain avg rating 2.0★)
2/5
Health inspection rating (on-site)
1
Serious findings on record
$64,604
Fines, last 3 years
2.88
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Dec 13, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Dec 14, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (40)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 2, 2026 | F · Potential for harm, facility-wide | The facility did not give residents the required written notice of their rights, the facility's rules, the services offered, and what those services cost. · from a complaint |
| Apr 2, 2026 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Apr 2, 2026 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · from a complaint |
| Apr 2, 2026 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 2, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 2, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Apr 2, 2026 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Apr 2, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Apr 2, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Apr 2, 2026 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Apr 2, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Apr 2, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Apr 2, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Apr 2, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 2, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Apr 2, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Apr 2, 2026 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Apr 2, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Sep 25, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint |
| Sep 25, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Sep 25, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Sep 25, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Sep 25, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Dec 13, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| May 30, 2024 | F · Potential for harm, facility-wide | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| May 30, 2024 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| May 30, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| May 30, 2024 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| May 30, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 30, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| May 30, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| May 30, 2024 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| May 30, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 30, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 27, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Apr 27, 2023 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Apr 27, 2023 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Apr 27, 2023 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Apr 27, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Apr 27, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (10 → 18).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 6 | 0 | D |
| 2024 | 11 | 1 | J ▲ |
| 2025 | 5 | 0 | D |
| 2026 | 18 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $64,604.
| Date | Type | Amount / length |
|---|---|---|
| Dec 13, 2024 | Fine | $64,604 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Ohio avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.88 | 3.45 | 3.95 | bottom 16% in Ohio; bottom 10% in the U.S. |
| Registered Nurse hours | 0.81 | 0.60 | 0.69 | top 13% in Ohio; top 27% in the U.S. |
| Weekend total nurse staffing | 2.48 | 3.07 | 3.50 | bottom 12% in Ohio; bottom 9% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.87 | 0.42 | 0.48 | top 3% in Ohio; top 9% in the U.S. |
| Total nursing staff turnover (%) | 60.0 | 48.7 | 45.8 | bottom 21% in Ohio; bottom 17% in the U.S. |
| RN turnover (%) | 36.8 | 43.9 | 42.9 | top 38% in Ohio; top 41% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.05, RN 1.14, weekend 3.49. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Donenbaum, Eli | Individual | 5% or Greater Indirect Ownership Interest | — | 06/20/2024 |
| Friedman, Devora | Individual | 5% or Greater Indirect Ownership Interest | — | 06/20/2024 |
| Friedman, Leba | Individual | 5% or Greater Indirect Ownership Interest | — | 06/20/2024 |
| Friedman, Matis | Individual | 5% or Greater Indirect Ownership Interest | 50% | 06/20/2024 |
| Hingj INC. | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/20/2024 |
| Mahilnitski, Ilya | Individual | 5% or Greater Indirect Ownership Interest | 15% | 06/20/2024 |
| Meb Irrv Tr | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/20/2024 |
| Neal, Kerry | Individual | 5% or Greater Indirect Ownership Interest | — | 06/20/2024 |
| Oheads Opco Holdings LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 06/20/2024 |
| Rap 118 LLC | Organization | 5% or Greater Indirect Ownership Interest | 15% | 06/20/2024 |
| Strauss, Jennifer | Individual | 5% or Greater Indirect Ownership Interest | — | 06/20/2024 |
| Yfr Equities LLC | Organization | 5% or Greater Indirect Ownership Interest | 5% | 06/20/2024 |
| Both, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/20/2024 |
| Both, John | Individual | ADP of the SNF | NOT APPLICABLE | 06/20/2024 |
| Friedman, Matis | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/20/2024 |
| Friedman, Matis | Individual | ADP of the SNF | NOT APPLICABLE | 06/20/2024 |
| Mahilnitski, Ilya | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/20/2024 |
| Rap 118 LLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/20/2024 |
| Wilson, Gary | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/20/2024 |
| Wilson, Gary | Individual | ADP of the SNF | NOT APPLICABLE | 06/20/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Can I get a written copy of resident rights, house rules, and a full list of services and charges today?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Parkview Care Center | 0.8 mi | Fremont, OH | ★★☆☆☆ | 1/5 | |
| Valley View Health Campus | 2.8 mi | Fremont, OH | ★★★★☆ | 3/5 | |
| Countryside Manor Nursing and Rehabilitation LLC | 3.1 mi | Fremont, OH | ★☆☆☆☆ | 1/5 | |
| Spring Creek Nursing and Rehabilitation Center LLC | 8.0 mi | Green Springs, OH | ★☆☆☆☆ | 2/5 | |
| Windsor Lane Healthcare Center | 9.1 mi | Gibsonburg, OH | ★★★☆☆ | 2/5 | abuse |
| Majestic Care of Clyde | 9.9 mi | Clyde, OH | ★★☆☆☆ | 2/5 | abuse |
| Ottawa Co Riverview Nursing Ho | 12.5 mi | Oak Harbor, OH | ★★★★☆ | 3/5 | |
| Willows at Bellevue | 14.4 mi | Bellevue, OH | ★★★★★ | 4/5 | |
| Edgewood Manor Rehabilitation & Healthcare Center | 14.9 mi | Port Clinton, OH | ★☆☆☆☆ | 2/5 | abuse |
| Genoa Retirement Village | 15.8 mi | Genoa, OH | ★★★★★ | 4/5 | |
| Autumnwood Care Center | 16.1 mi | Tiffin, OH | ★★☆☆☆ | 2/5 | |
| The Willows at Tiffin | 17.1 mi | Tiffin, OH | ★★★★★ | 5/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 365510.