Bethesda Dilworth

Inspectors wroteBased on interview, observation, and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation when the shift change narcotic count was not completed and one of the narcotic count sheets for one resident was inaccurate (Resident #7). The sample was 14. The census was 152 with 130 in certified beds. Review of the facility's Inventory Control of Controlled Substances Policy, revised 8/2023, showed:-Purpose: This policy sets forth the procedures for inventory control of controlled substances and establishes guidelines for the investigation of missing medications;-Scope: Level 2 policy affecting contracted pharmacies, Human Resources, nursing staff, and nursing management;-Responsibility: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure on-going resident centered therapeutic activities were provided to residents in the evenings and weekends as an integral part of their psychosocial well-being. In addition, the facility failed to ensure activities were offered to all residents who wished to attend (Residents #140, #155 and #99). This deficient practice had the potential to affect all residents in the facility who wished to attend activites. The sample size was 25. The census was 145 with 126 in certified beds.1. During an interview on 7/23/25 at 8:31 A.M., the administrator said the Garden Terrace activity's calendar was the main calendar used for all activities in the facility. Review of the Garden Terrace Activity's Calendar, dated June 2025, showed: -Monday through Friday, no activities offered after 2:30 P.M.; [...]

Inspectors wroteBased on interview and record review the facility failed to follow their grievance policy and procedure for residents and family members to voice grievances and prompt the facility to resolve grievances for one resident (Resident #9). The failure has the potential to affect all residents. The sample size was 13. The census was 146 with 119 in certified beds. Review of the facility's Resident and Family Grievances policy, revised, February 2025, showed: -Purpose: To establish written guidelines for the filing of residents' grievances and to ensure that appropriate investigation and actions are promptly taken; Customer feedback is an important source of information about an organization's performance; The verbal or written resident grievances received by staff, physicians, and administration provide vital information about improvement opportunities. -Definitions: [...]

Inspectors wroteBased on interview and record review, the facility failed to assure the resident's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) accurately reflected the resident's status for one of three residents investigated for hospice (Resident #147). The facility identified 19 residents on hospice. The census was 145 with 126 in certified beds. Review of Resident #147's medical record, showed diagnoses included dementia, Chronic Obstructive Pulmonary Disease (COPD, lung disease), depression, anxiety, and malnutrition;-An electronic physician order sheet (ePOS) showed an order dated [DATE], for a Hospice consult;-A hospice election form showed hospice services began [DATE]. Review of the resident's significant change MDS, dated [DATE], showed:-Assessment Reference Date (ARD) [DATE];-Special services received while a resident: Hospice Care not marked; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two dependent residents received Activities of Daily Living (ADL) care (Residents #2 and #8). The sample was 25. The census was 145 with 126 in certified beds. Review of the facility's ADL care policy, dated October 2022, showed:-Purpose: To provide grooming and hygiene for each resident, assisting with bathing, dressing and elimination as needed;-Policy: It shall be the policy of the facility that each resident receives assistance with ADLs as needed throughout each day. Consideration will be given to making the experience as home-like and individual as possible;-Procedure: Give nail care as needed. Assist each resident with grooming. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an acceptable skin management program was maintained to prevent pressure injury development and to report changes timely to the physician. The facility failed to complete wound assessments, including assessment and documentation of the location, stage, size, wound characteristics, periwound (the area around the wound) and wound edge description for two residents. (Residents #1 and #2). In addition, the facility failed to follow their policy for wound photographs and measurements for three residents (Resident #1, #2, and #3). The facility failed to contact Resident #1's physician prior to entering an order for a treatment. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify three residents physician and the representative/appropriate family member after the residents had a change in condition (Resident #1, #2, and #3). The sample was 4. The census was 151. Review of the facility's policy, Reporting of Condition Changes, incidents and injuries, revised 1/23, showed: -Purpose: To provide an orderly process for reporting changes in condition, incident or injuries involving residents; -Responsibility: It will be the responsibility of the licensed nurses to know and follow this policy; -Policy: It is the facility policy to report condition changes, incidents or injuries involving residents; -Practice: When reporting changes in condition or incidents, the following procedure should be followed: -1. Evaluate symptoms and/or injury. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals and needs, desire to be discharged , the resident's capacity for discharge, including caregiver support availability, capacity, and capability to perform required care, and failed to involve the resident, family member, and the interdisciplinary team (IDT) in developing a discharge plan, with interventions to meet the resident's discharge goals and needs to ensure a smooth and safe transition to the post-discharge setting and reduce factors leading to preventable readmissions. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pressure ulcer treatments as ordered and failed to notify the physician when the ulcer developed drainage and a foul odor, shortly before the resident was discharged . The resident was discharged to home, alone, without home health registered nursing care services, and without education or instructions of how to care for the coccyx/sacral wound. Five residents were sampled, and problems were identified with one (Resident #5). The census was 149. Review of the facility policy for Skin Integrity, Assessment, and Prevention of Wounds/Other Skin Conditions, revised on 9/2022, showed: -Purpose: -To prevent avoidable skin breakdown and pressure injuries; -Provide guidelines for the treatment of impaired skin; -Provide guidelines for documentation. -Policy: -All residents will be assessed for the risk of skin breakdown; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards. Staff failed to ensure a resident admitted from the hospital with a peripherally inserted central catheter (PICC, a thin, flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart, used to administer long term antibiotics and other medications) line, had orders for the PICC line including PICC line maintenance. Staff failed to verify why the PICC line was in place and failed to obtain and ensure continuity of antibiotic administration from the hospital related to a bacterial infection. The resident was not administered antibiotic medication for two days after admission into the facility (Resident #1). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for one resident (Resident #1) who required staff assistance with transfers and mobility when going to bed. On [DATE], after the resident became adamant about staff putting him/her to bed, staff removed the resident from a sit to stand lift (a medical device that assists individuals with limited mobility in standing up from a seated position) and performed a 2-person assist transfer. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse and neglect policy by not reporting timely after an incident involving one resident (Resident #1) and two staff, who performed an improper transfer which resulted in the resident sustaining a comminuted tibial plateau fracture (a break in the lower bone below the knee that breaks into the knee joint and is displaced and not aligned) involving the medial (the bony surface on the top of the shin bone that corresponds to the big toe) and lateral (the surface that corresponds to the pinky toe) tibial plateau without significant displacement. The sample size was 3. The census was 149. Review of the facility's Resident Abuse, Neglect, and Exploitation policy and procedure, revised 7/2023, showed: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an appropriate immediate discharge letter to one of four sampled residents (Resident #1). The letter failed to contain the effective date of discharge, specific location to where the resident was transferred and discharged , failed to provide information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request, along with the failure to inform the resident he/she can return to the facility if an appeal is filed. Additionally, the Long-Term Care Ombudsman's office address was incorrect, and no email address was listed. The census was 147. Review of the facility's Discharge/Transfer of a Resident policy, dated 12/2022, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 28 opportunities for errors, three errors occurred, resulting in a 10.71% medication error rate (Residents #11, #7 and #272). The sample was 26. The census was 148 with 129 in certified beds. Review of the facility's Medication Administration-General Guidelines Policy, revised 6/2023, showed: -Policy: Only a licensed nurse or Certified Medication Technician (CMT) may prepare, administer and/or record the administration of medications. Medications must be administered in accordance with a physician's order (i.e., the right resident, the right medication, the right dosage, the right route and the right time). Medications must always be prepared, administered and recorded by the same nurse/CMT; -Administration: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who lived on the Rehab Unit were served hot foods at appropriate temperatures of at least 120 degrees Fahrenheit (F) at the time of service. Three residents were interviewed about food temperatures and all three said hot foods were frequently too cold (Residents #14, #172 and #173). The census was 148 with 129 in certified beds. Review of the facility's Meal Temperature policy, dated 1/21/21, showed the following: -Policy: All food items are evaluated for proper food temperature, taste and appearance prior to meal service. Food and drinks should be palatable, attractive and served at a safe and appetizing temperature, as determined by the type of food, to ensure patients'/residents' satisfaction; -Procedure: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow one resident's (Resident #222) wishes of Do Not Resuscitate (DNR, instructs health care providers not to do cardiopulmonary resuscitation (CPR, a lifesaving technique useful in which someone's breathing or heartbeat has stopped) if a patient's breathing or heartbeat has stopped). On [DATE] at 6:00 A.M., the resident was found on the floor, unresponsive and without a pulse. The nurse obtained the wrong chart and performed CPR on the resident for approximately 15 minutes prior to realizing the error. In addition, five out 26 residents reviewed for code status had code status/physician's orders for code status sheets not signed by the physician (Residents #102, #19, #99, #372, and #371). The census was 148 with 129 in certified beds. Review of the facility's Life Sustaining Treatment policy, last reviewed [DATE], showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their Inventory Control of Controlled Substances policy when staff failed to count/document daily controlled substances. 26 controlled substance shift change count sheets (narcotic sheets) were reviewed and issues were found with 18. The census was 148 with 129 in certified beds. Review of the facility's Inventory Control of Controlled Substances policy, last reviewed 8/2022, showed Community should ensure that incoming and outgoing nurses count all Scheduled II-V controlled substances (a drug or chemical whose manufacture, possession and use is regulated by a government) and Tramadol (medication used to treat pain) daily with both (staff) documenting verification on the Controlled Substance Log. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. The facility identified five medication rooms, 10 medication carts, five treatment carts and one respiratory cart. Three of five medication rooms, two of five treatment carts, five out of ten medication carts and one of one respiratory carts were checked for medication storage. Issues were found with one medication room when staff failed to date one opened vial of purified protein derivative (PPD, used in skin test to help diagnose silent (latent) tuberculosis (TB) infection) and one treatment cart, when staff failed to date six out of 10 opened insulin pens and one medication cart and when staff failed to date one out of two opened insulin pens and stored one vial of PPD on the medication cart. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were able to self-administer medication only if the interdisciplinary team has determined that this practice is clinically appropriate, for one resident found to have medications left on the dining room table in front of the resident (Resident #73). The census was 201 with 164 in certified beds. Review of the facility's self-administration of medication policy, revised 8/2018, showed: -Policy: Medications may be self-administered only after the resident has been evaluated by an interdisciplinary team to determine that the resident can safely self-administer medications and with administrator/executive director approval; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident comprehensive care plans were implemented when staff failed to place fall mats beside a resident's bed and ensure Styrofoam plates were provided for a resident who threw plates, for two residents (Residents #99 and Resident #12) out of 32 sampled residents. The census was 201 with 164 in certified beds. 1. Review of Resident #99's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/19, showed: -Severe cognitive impairment; -One staff assist for bed mobility, transfers, dressing, toileting and personal hygiene; -Pain, yes; -Falls, yes, two or more; -Diagnoses included stroke. Review of the resident's care plan, in use during the survey, showed: -Focus: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided treatment in accordance with professional standards of care, when the facility administered a tube feeding for one resident (Resident #148) while the resident lay flat in the bed. The sample was 32. The census was 201 with 164 in certified beds. Review of Resident #148 admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/15/20, showed the following: -The resident had severe cognitive impairment; -The resident needed extensive to total assistance with grooming, dressing and bathing; -Nutritional approach was marked for feeding tube; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the facility policy and ensure an indwelling urinary catheter (a tube that collects urine from the bladder and leads to a drainage bag) drainage bags remained off the floor for multiple days of the survey. The facility also failed to ensure a catheter drainage bag remained covered and unexposed to the hallway. This affected two of the five residents identified by the facility as having an indwelling urinary catheter (Residents #317 and #155). The census was 201 with 164 in certified beds. Review of the facility's catheter care policy, revised 4/2019, showed: -Purpose: To provide guidelines for proper care of the indwelling catheter and drainage bag to prevent complications; -Responsibility: It is the responsibility of all nursing staff to know and follow the procedure; -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 25 opportunities observed, three errors occurred resulting in a 12% error rate (Resident #417). The census was 201 with 164 in certified beds. Review of the Resident #417's electronic physician order sheet (ePOS), showed: -An order dated 1/27/20, for amiloride (diuretic) 5 milligram (mg) daily; -An order dated 1/28/20, for Losartan (used to treat high blood pressure) 100 mg daily; -An order dated 2/3/20, for prednisone (steroid) 5 mg. Administer one tablet daily. During a medication administration observation on 2/5/20 at 8:18 A.M., Certified Medication Technician (CMT) B administered medications to the resident. He/she administered prednisone 5 mg, four tablets to equal 20 mg. He/she failed to administer amiloride and Losartan to the resident. [...]