Bethesda Lutheran Communities, Inc.

Case # (*) Summary

Self-Report or


Date of

Incident Discovery

Date Reported

to OIG

Date OIG

Report Issued

Written Response

Due Date

Date Written

Response Received


Approval Date (**)

1018-0521 (pdf) The accused let the victims alone in the CILA between 1:00 AM and 4:00 AM. This was discovered when the fire alarm went off and one of the victims called the house manager. Self-Report 6/16/18 6/18/18 8/16/18 9/15/18 9/27/18 9/27/18 (pdf)
1118-0139 (pdf) Accused made demeaning comments to the victim causing maladaptive behavior. Self-Report 10/5/17 10/5/17 6/14/18 7/14/18 6/28/18 6/28/18 (pdf)
1118-0326 (pdf) Accused failed to document changes to victim's skin and reposition her, causing pressure sores to form. Self-Report 2/13/18 2/13/18 7/20/18 8/1918 7/31/18 7/31/18 (pdf)

* - Click Case # for executive summary of case report

** - Click Final Approval Date for final version of written response

Please note: Only substantiated cases with written response due dates after January 1, 2018 are posted and, then, only after the written response

due date is reached.