Bethesda Care Center

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to ensure the Minimum Data Set (MDS) was accurately coded. This affected four residents (#25, #31, #36 and #15) and had the potential to affect 13 residents the facility identified as receiving respiratory services at the facility. The facility census was 82.

Inspectors wroteBased on observations, staff interview, and policy review, the facility failed to provide activities to meet the residents' needs and cognitive capabilities. This affected 24 residents who reside in the memory care unit. The facility census was 82.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure hazardous chemicals and medications were properly stored. This had the potential to affect 10 residents (#9, #11, #22, #26, #32, #45, #54, #59, #63, and #73) who the facility identified to be cognitively impaired and independently mobile on the 200 hall. The facility census was 82.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure food that was opened was properly stored. This had the potential to affect 79 residents who the facility identified to receive food from the kitchen. The facility census was 82.

Inspectors wroteBased on medical record review, observation, resident and staff interviews, and review of facility policies, the facility failed to ensure personal protective equipment was utilized for residents in contact precautions. This affected one (Resident #85) of one resident reviewed for contact precautions. Additionally, the facility failed to ensure hand hygiene was performed while delivering meal trays to resident rooms. This affected four (Residents #8, #14, #51, and #85) of 13 residents observed for meal tray delivery.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to provide a comfortable and homelike environment for residents on Memory Care (MC) unit. This had the potential to affect all 24 residents who reside on the MC unit. The facility census was 82. Findings Include: Observation of the MC unit on 03/30/26 at 12:06 P.M. revealed the wall carpet was peeling and unsightly, wallpaper between resident rooms [ROOM NUMBERS] was peeling, two air vents near the nurse's station were visibly soiled, and a ceiling tile near the nurse's station was missing. Interview on 03/30/26 at 12:07 P.M. with Licensed Practical Nurse (LPN) #230 confirmed the wall carpet and wallpaper were peeling and unsightly. Interview on 03/30/26 at 12:08 P.M. with Registered Nurse (RN) #270 confirmed the air vents were dirty and the ceiling tile was missing. [...]

Inspectors wroteBased on medical record review, resident interviews, staff interview, and review of facility policy, the facility failed to ensure residents completed bathing according to their preferences. This affected one (Resident #85) of one resident investigated for choices. The facility census was 82.

Inspectors wroteBased on medical record review, staff interview, family interview, and review of the facility policy, the facility failed to ensure the physician was notified timely when a resident had a change of condition. This affected one (Resident #91) of one reviewed for notification of change. The facility census was 82.

Inspectors wroteBased on review of Self-Reported Incident Investigation, facility investigation, medical record review, staff interview, and policy review, the facility failed to ensure one (Resident #10) was free of misappropriation of narcotic medications. This affected one, Resident #10 of one reviewed for misappropriation. This had the ability to affect 18 Residents (#4, #5, #10, #25, #27, #29, #31, #36, #37, #41, #50, #56, #57, #58, #60, #65, #68, and #70) identified as receiving narcotic medication. The facility census was 82.

Inspectors wroteBased on record review, staff interview, review of the Gradual Dose Reduction (GDR) document, and policy review, the facility failed to ensure a GDR was acknowledged and signed by the physician for one resident (#72) of five residents reviewed for unnecessary medications. The facility census was 82.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a compreshensive care plan was completed including the use of oxygen therapy for one resident (#15) of three residents reviewed for oxygen. The facility census was 82.

Inspectors wroteBased on medical record review, observation, staff interview, family interview, and policy review, the facility failed to ensure Activities of Daily Living (ADL) care was provided for dependent residents. This affected two residents, (#54 and #63) of three residents reviewed for ADL care. The facility census was 82.

Inspectors wroteBased on medical record reviews, review of an Emergency Medical Service (EMS) run report, staff and resident interviews, and review of facility policies, the facility failed to ensure follow up care was provided when skin breakdown was noted, failed to document skilled assessments, vital signs, and failed to notify the physician regarding a change of condition. The facility also failed to implement physician orders following an office visit. This affected two (Residents #77 and #91) of two residents reviewed for quality of care. The facility census was 82.

Inspectors wroteBased on observation, resident interview, staff interview, record review, and review of facility policy, the facility failed to ensure implementation of physician-ordered pressure ulcer prevention interventions for one (Resident #7) of two reviewed for pressure ulcer. The facility census was 82. Findings Include: Review of the medical record for Resident #7 revealed an admission date of 12/09/25 with multiple diagnoses, including peripheral vascular disease, congestive heart failure, chronic obstructive pulmonary disease, and generalized weakness. Review of Resident #7's most recent quarterly Minimum Data Set (MDS) assessment, dated 02/16/26, revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Further review revealed Resident #7 required assistance with all activities of daily living, including bed mobility and repositioning. [...]

Inspectors wroteBased on observation, staff interview, resident interview, medical record review, and review of facility policy, the facility failed to ensure orders for supplemental oxygen were in place for one residents (#15). This affected one residents (#15) of four residents reviewed for respiratory care. The facility census was 82. Findings Include: Review of Resident #15's medical record revealed an admission date of 11/14/24. Diagnoses included acute respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), heart failure, hypertension, type two diabetes mellitus, and generalized anxiety disorder. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of seven. [...]

Inspectors wroteBased on medical record review, interview, and review of the facility policy, the facility failed to ensure a dialysis port was monitored. This affected one (#4) of one resident reviewed for dialysis. The facility census was 82.

Inspectors wroteBased on Self-Reported Incident review, medical record review, and staff interview, the facility failed to ensure medications documentation was completed accurately for one (Resident #10). This had the potential to affect 18 residents (#4, #5, #10, #25, #27, #29, #31, #36, #37, #41, #50, #56, #57, #58, #60, #65, #68, #70) the facility identified as receiving opioid medication in the facility. The census was 82. Findings Include:Review of Resident #10's medical record revealed an admission date of 06/21/25. Diagnosis included congestive heart failure, end stage heart failure, Diabetes Mellitus Type II, and chronic obstructive pulmonary disease. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident code status orders accurately reflected their wishes as documented in their Advance Directives Form. This affected one resident (#40) of three residents (#33, #40, and #68) reviewed for code status. The facility census was 75. Findings Include:Review of the medical record for Resident #40 revealed an admission date of 07/23/25. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident care plans accurately documented their code status. This affected one resident (#40) of three residents (#33, #40, and #68) reviewed for care planning. The facility census was 75. Findings Include:Review of the medical record for Resident #40 revealed an admission date of [DATE]. [...]

Inspectors wroteBased on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure routine medications were supplied to residents. This affected one resident (#40) of three residents (#33, #40, and #77) reviewed for pharmacy services. The facility census was 75. Findings Include:Review of the medical record for Resident #40 revealed an admission date of 07/23/25. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure injectable medication was dated and labeled. This affected two residents (#23 and #42) identified by the facility as being prescribed injectable medication and residing on the 100-hall. The facility census was 75. Findings Include:Observation on [DATE] at 9:49 A.M. of the medication storage cart for the 100-hall with Licensed Practical Nurse (LPN) #175 revealed a Lantus SoloStar Pen insulin glargine (a type of long-acting insulin), 100 units per milliliter (units/mL), with approximately 60 of 300 units remaining, with a manufacturers date of [DATE], that was unlabeled with the date it was opened or the date it expired. Interview at the time of observation with LPN #175 verified the Lantus SoloStar Pen was unlabeled with the date it was opened or the date it expired. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure an effective infection prevention program was followed. This affected one resident (#26) of three reviewed for infection control related to wound care. The facility census was 75. Findings Include:Review of the medical record for Resident #26 revealed and admission date of 04/15/25. Diagnoses included cerebral infarction, benign prostatic hyperplasia (BPH), Barrett's esophagus, diverticulosis of large intestine without perforation, gastric ulcer, gastrointestinal (GI) hemorrhage, diaphragmatic hernia without obstruction or gangrene, hyperlipidemia, atrial fibrillation (a. [...]

Inspectors wroteBased on review of electronic medical records, review of emergency medical squad report, review of hospital records, review of staff education, staff interviews, review of text message review of facility policies, and resident family interview, the facility failed to ensure Resident #76 received medications to prevent seizure activity and notify the physician of resident not receiving medications and having seizure activity. [...]

Inspectors wroteBased on employee file review, staff interview and review of facility policy, the facility failed to ensure State Tested Nursing Assistants (STNAs) had evaluations completed as required. This had the potential to affect all 68 residents residing in the facility. The facility census was 68. Findings Include: Review of the employee file for State Tested Nursing Assistant (STNA) #555 revealed a hire date of 11/11/22. No annual performance evaluations were found. Review of the employee file for STNA #557 revealed a hire date of 12/18/23. A 90 day performance evaluation was not found. Interview on 05/30/24 at 8:57 A.M. with the Administrator verified State Tested Nursing Assistant (STNA) #555 did not have an annual evaluation completed and STNA #557 did not have her 90 day evaluation completed. [...]

Inspectors wroteBased on observation, staff interview, census list review, and policy review, the facility failed to ensure the flooring was maintained in a clean and appropriate condition. This affected fifteen (#2, #6, #9, #15, #25, #43, #45, #49, #56, #58, #60, #61, #62, #69, and #70) residents in the memory care unit. The census was 68.

Inspectors wroteBased on observation, resident interview, staff interview medical record review and review of facility policy, the facility failed to ensure resident preferences of room temperatures were honored. This affected two (#39 and #40) of three residents reviewed for choices. The facility census was 68. Findings Include: 1. Review of Resident #39's medical record revealed an admission date of 05/09/24. Diagnoses included type II diabetes, emphysema, chronic obstructive pulmonary disease, morbid obesity, and depression. Review of Resident #39's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #39 was cognitively intact. Resident #39 required limited assistance for transfers and two person physical assistance with toilet use. Resident #39 displayed no behaviors during the review period. [...]

Inspectors wroteBased on medical record review, observation, resident interview, staff interview and review of the facility and review of facility policy the facility failed to ensure appropriate and timely care and services to assist with hearing. This affected one (#53) of three residents reviewed for hearing. The facility census was 68.

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to complete neurology checks on a resident with an unwitnessed fall per facility policy. This affected one (#29) of one resident reviewed for falls. The facility census was 68.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to ensure portable oxygen tanks were sufficiently supplied with available oxygen for resident use. This affected one resident (#267) reviewed for oxygen use. The facility identified 12 residents who were on oxygen therapy. The facility census was 68.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview and review of facility policy, the facility failed to maintain accurate physician orders and failed to accurately assess a dialysis access site. This affected one (#30) of one resident reviewed for dialysis. The facility identified six residents who received dialysis. The facility census was 68.

Inspectors wroteBased on medical record review, observations, staff interview and review of the facility policy, the facility failed to ensure timely psychiatric follow-up for a resident experiencing an exacerbation of mood symptoms. This affected one (#33) of one residents reviewed for behavioral services. The facility census was 68.

Inspectors wroteBased on observations of medication storage, medical record review, staff interview, review of the manufacturer's recommendations and policy reviews, the facility failed to ensure insulins were dated when opened and failed to ensure expired insulins were discarded. This affected three (#10, #20, and #267) of three residents medications observed for medication storage. The facility census was 68.

Inspectors wroteBased on observation, resident interview, staff interview, and review of the policy, the facility failed to ensure used soiled bed pans were stored appropriately in a shared bathroom. This affected one (#38) of one resident reviewed for used bed pan storage in a shared bathroom. The facility census was 68.

Inspectors wroteBased on resident and staff interviews, review of a resident concern form, and review of facility policy, the facility failed to ensure residents were treated with dignity and respect. This affected three (Residents #21, #28, and #42) of three reviewed for dignity. The facility census was 63.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure bilateral grab bars were in place on a resident's bed per physician orders. This affected one (Resident #25) of two residents reviewed for position and mobility. The facility census was 63.

Inspectors wroteBased on Beneficiary Protection Notification Review and staff interview, the facility failed to ensure Advanced Beneficiary of Non-Coverage (ABN) notifications were issued to residents who remained in the facility following termination of Medicare Part A services. This affected two (Residents #21 and #40) of three residents reviewed for beneficiary notice protection. The facility census was 63.

Inspectors wroteBased on medical record review, observation, staff interview, resident interview, and review of facility policy, the facility failed to ensure residents were provided an environment with comfortable sound levels. This affected one (Resident #22) of three reviewed for comfortable sound levels. The facility census was 63.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to provide care and services to potentially prevent additional and/or worsening pressure ulcers. This affected one (Resident #34) of two residents reviewed for pressure ulcers. The facility census was 63.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview and review of facility policy, the facility failed to ensure oxygen supplies were dated when initiated according to physician orders. This affected one resident (#42) of five residents reviewed for oxygen therapy. The facility census was 63.