Bethesda Home of Aberdeen

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure pressure injury prevention interventions were identified and implemented for one of one sampled resident (70) who developed a deep tissue injury (DTI) (a pressure ulcer/injury with purple or maroon discolored skin and underlying soft tissue damage, caused by intense, prolonged pressure) on her right heel.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the staff followed food safety standards to:*Maintain a clean and sanitary food service environment in one of one main kitchen and one of one activity room kitchenette.*Store raw meat to prevent potential cross-contamination in one of one walk-in cooler.*Label and date bulk food ingredients in one of one activity room kitchenette according to the provider's policy.*Ensure one of one activity room dishwasher used for special events reached the temperature required for sanitizing residents' drinkware and dishes.*Ensure hand hygiene (washing hands or using hand sanitizer) was performed after direct contact with soiled surfaces and resident equipment by certified nurse aide (CNA) (M) before the CNA poured water into glasses for three of three sampled residents (1, 19, and 67) during one of two [...]

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure the menu serving sizes and therapeutic diet menus were created and followed regarding:*One of one chef (P) failed to follow the menu serving sizes for each resident who was offered food at the facility for one of two observed meal services.*Nine of nine sampled residents (1, 7, 15, 17, 42, 48, 53, 75, and 90) who were prescribed a NAS (no added salt) diet, and eighteen of eighteen residents (9, 20, 21, 23, 27, 32, 33, 40, 41, 46, 50, 57, 63, 68, 71, 78, 79, and 87) who were prescribed a Heart healthy diet, and did not have their therapeutic diet created or followed.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the staff educated the resident or resident's representative of the risk versus benefits of medications or of alternative treatments to make an informed decision for the consent for the use of psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) before they were given for two of two sampled residents (7 and 10).

Inspectors wroteBased on observation, interview, record review, and the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 review revealed the provider failed to ensure staff electronically submitted Minimum Data Set Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessments to the Center for Medicare and Medicaid Services (CMS) within the required 14 day time frame from the residents' discharge for three of three sampled discharged residents (33, 43, and 92).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (2) with dementia and episodes of hallucinations, behaviors, and agitation, had person-centered interventions included in the resident's plan of care for the staff to implement to assist the resident during those episodes to meet her dementia care needs.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure the staff followed nursing professional standards related to following physician orders regarding blood glucose monitoring and physician notification for one of one sampled resident (3) who had low blood sugar levels, and oxygen saturation (percentage of oxygen in the blood) monitoring for one of one sampled resident (32) with physician's orders to keep her oxygen saturation levels above 90 percent.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure safe food was at safe temperatures prior to serving residents food by one chef (H) during an observed breakfast meal service.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to develop in collaboration with hospice a comprehensive care plan for one of one resident (288) who received oxygen and hospice services.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to maintain the cleanliness of the oxygen concentrator, tubing, and humidifier and to administer the nebulizer treatment appropriately after determining the resident could not self-administer that treatment for one of one observed sampled resident (288) who received oxygen.

Inspectors wroteBased on record review, interview, and review of the Hospice and Nursing Facility Services Agreement, the provider failed to ensure an integrated plan of care had been developed and made accessible between the provider's nursing staff and hospice agency for one of one sampled resident (288) who received hospice services.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure: *One of seven refrigerators was set at an appropriate temperature for safe food storage. *Two of seven refrigerators were monitored for safe temperature control. 1. Observations on 7/24/23 at 3:27 p.m. in the kitchen revealed: *The south refrigerator had four glass doors. *The gasket around the bottom right door was torn in several places. *The thermometer on the front of the refrigerator read 51 degrees. *The thermometer on the inside of the refrigerator read 58 degrees. *Refrigerator temperatures should be maintained between 35 and 41 degrees. *The refrigerator contained the following: -Fifty-nine bowls of cherry crisp dessert. -thirty-three bowls of lettuce salad. -thirty-six cups of French salad dressing. -Six ham salad sandwiches. -Two cakes labeled Hawaiian. [...]