Bethesda Home

Inspectors wroteBased on interview and record review the facility failed to schedule a registered nurse (RN) for eight consecutive hours a day, seven days a week, for 86 days in 2024. This failure had the potential to place residents at risk to receive insufficient care.

Inspectors wroteBased on interview and record review the facility failed to ensure four out of four Certified Nursing Assistants (CNAs) and one out of one Certified Nursing Assistant Lead (CNAL) had the appropriate competencies to care for residents when the facility did not complete Annual Performance Evaluations for CNAs 1, 2, 3 and 4 and CNAL. This failure had the potential for resident care to be provided in an unsafe and incompetent manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were appropriately acquired, received, and dispensed when: 1. One oral (administered by mouth) emergency medication kit (E-Kit) was not replaced within 72 hours after opening. 2. One injectable (medications that are administered into the body using needle and syringe) E-Kit had 15 expired medications. These failures had the potential to result in delayed treatments during emergency situations and placed residents at risks for receiving expired medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. During the medication pass, two medication errors were observed out of 33 opportunities for two of four residents ((Resident 16, Resident 24) resulting in an error rate of 6.06 percent. 1. Mirabegron (medication for overactive bladder) extended release 25 mg 1 tablet oral (by mouth) was crushed and administered to Resident 16. 2. Timolol maleate eye drops were not properly administered to Resident 24. These deficient practices resulted in medication not given in accordance with the manufacturer's specifications and per the standard professional practice, which may result in residents not receiving the full therapeutic effects of the medications.

Inspectors wroteBased on interview and record review the facility failed to employ a full time Dietary Manager (DM) while they had a part time Registered Dietician (RD). This failure had the potential to result in inadequate resident kitchen oversight and placed 32 residents who received food from the kitchen, at risk to receive inadequate nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared under sanitary conditions when: 1. The freezer had three food items not labeled with date. 2. The freezer had two food items unsealed and open to air. 3. Staff did not wear a beard restraint while preparing resident food. 4. Resident refrigerator had three unlabeled and undated food items. 5. Six dry foods were stored less than 6 inches above the ground. 6. One expired canned food was available for resident use. 7. The refrigerator had one box of rotten bell peppers. These failures had the potential to put 32 residents at risk for cross contamination and food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for three (Resident 2, Resident 4, and Resident 16) of 34 sampled residents when licensed staff did not sanitize the reusable medication tray in between use for the residents and did not perform hand hygiene in between medication pass for Resident 16. These failures had the potential to result in cross contamination and spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure there was sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services for 13 of 14 residents on a pureed diet (food blended to a smooth consistency similar to pudding, mashed potatoes, or applesauce). The failure to employ either a full-time dietician, or a certified dietary/food service manager resulted in inadequate oversight of kitchen staff and improper pureed diet food preparation and had the potential to result in inadequate nutrition for residents on pureed diets. See also tag F 805.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the facility's recipes for 13 of 13 residents on pureed diets (pureed food is food blended to a smooth consistency similar to mashed potatoes, pudding, or applesauce). This failure resulted in unknown nutritional content of pureed meats, vegetables, and starches, and had the potential to result in inadequate nutritional intake for residents on pureed diets. See also tag F 801.

Inspectors wroteBased on interview and record review, for 37 of 37 residents, the facility failed to have measures in place for facility water systems to prevent the growth of Legionella (a bacteria spread through contaminated water which can lead to severe lung inflammation) and other water-borne pathogens (a virus, bacteria, or other organism that causes an illness). This failure had the potential to expose facility residents to water-borne pathogens, including Legionella, and result in illness and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to provide education about pneumococcal vaccinations (an injection to reduce to risk of getting pneumonia; an infection of the lungs) and failed to offer pneumococcal vaccination to three (Resident 30, Resident 1, and Resident 12) of five sampled residents. This failure resulted in lack of knowledge of advantages of pneumococcal vaccination and had the potential to result in increased risk of contracting pneumonia for Resident 30, Resident 1, and Resident 12.

Inspectors wroteBased on observation, interview, and record review, Licensed Vocational Nurse 1 (LVN 1) failed to protect the privacy of all 38 residents in the facility when the list of resident names with vital signs (clinical measurements that indicate the status of a person's essential body functions) was left unattended on top of the medication cart. This failure had the potential to result in unauthorized access to information pertaining to residents' medical condition.

Inspectors wroteBased on observation, interview, and facility document review the facility failed to: 1. Ensure the Registered Dietitian (RD) provided frequent consultation to Food and Nutrition Services Director; and 2. Employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. These failures resulted in inadequate oversight of kitchen staff to ensure staff were conducting job duties in a safe and sanitary manner, resulting in the potential for food borne illness for 38 residents who ate food from the kitchen out of a facility census of 38.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure kitchen staff competency when staff were not competent regarding their job duties. This failure had the potential for tasks not being carried out in a safe and sanitary manner resulting in contamination of utensils and equipment used by residents and food borne illness for 38 residents who ate food from the kitchen out of a facility census of 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 38 of 38 sampled residents had food prepared and stored in a safe and sanitary manner when: 1. Internal temperature of foods was above 41°F in the walk-in refrigerator and inaccurate thermometers were used to monitor temperatures of the refrigerator; 2. frozen meat was not thawed with proper procedures; 3. thawed meats and produce were not stored appropriately in the refrigerator; 4. staff did not perform hand hygiene moving from dirty to clean tasks; 5. staff did not follow manufacturer instructions for cleaning and sanitizing equipment; 6. food and supplements were stored outside of building without temperature control and exposed to pests; 7. moldy and unusable foods were not discarded; 8. staff did not follow sanitization steps for cleaning countertops; 9. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services policies and procedures were followed when: 1. Two partially tablet-filled medication administration cards, without expiration dates, were left out unattended on top of the medication cart; and 2. Licensed Vocational Nurse 2 (LVN 2) left the medication cart unlocked and unattended in the hallway. This failure had the potential for loss or misuse of medications and the potential to jeopardize the residents' health and safety and could cause other complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control practices for one resident for a census of 38 when the following was observed: 1. Registered Nurse (RN) 1 did not perform proper hand hygiene during wound care; 2. RN 1 did not use sterile gloves during wound care; 3. RN 1 did not sanitize overbed table before wound care; 4. RN 1 did not sanitize reusable supplies with alcohol; and 5. RN 1 did not dispose of contaminated supplies. These failures created a risk for cross-contamination (transfer of bacteria or other microorganisms from one substance to another) that could result in serious illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident 27) of five sampled residents received the necessary care to maintain good grooming and personal hygiene. This failure resulted in Resident 27 having long fingernails to his left contracted hand and had the potential to create discomfort, especially into the palm of his hand.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately label two of two (Resident 2 and Resident 25) sampled resident's medications when: 1. For Resident 2, there was inaccurate and not identical labeling between the Medication Administration Record (MAR), Physician Orders, (PO), and medication administration card to facilitate safe administration of medication; and 2. For Resident 25, the Licensed Vocational Nurse 1 (LVN 1) did not label and date newly administered transdermal patch to Resident 25's skin. This failure had the potential for Resident 2 to receive the wrong medication dose of Seroquel (a medication used to treat certain mental/mood disorders) and for licensed nurses' inability to monitor patch administration was given to the resident as ordered.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures to ensure all staff were fully vaccinated for COVID-19 (a highly infectious respiratory disease) when staff vaccination rate was less than 100% and Certified Nurse Assistant (CNA) 2 did not have a non-medical exemption for the COVID-19 vaccine. This failure resulted in staff not receiving COVID-19 vaccine series and boosters without valid exemption.