Bethesda

Inspectors wroteBased on observation, interview and document review, the facility failed to store food in accordance with professional standards for food safety in 1 of 2 refrigerators on the 100-units. This had the potential to affect all 40 residents that resided on the unit.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement proper enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) for 4 of 7 residents (R4, R16, R241, R55) and failed to implement proper enhanced respiratory precautions for 1 of 2 residents (R67) reviewed for transmission based precautions. In addition the facility failed to provide sanitary urinary catheter cares for 1 of 1 residents (R55) reviewed for catheter cares. Also the facility failed to complete appropriate hand hygiene for 1 of 1 residents (R67) observed for personal cares. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self-administration of medication assessment (SAM) was completed to allow residents to safely administer their own medications for 3 of 3 residents (R192, R151, R116 ) observed with medications at the bedside. R116 R116's quarterly MDS dated [DATE], identified R116 was cognitively intact and was dependent on staff with dressing, personal hygiene, and toileting. R166 had hypertension and was legally blind. R116 was frequently incontinent of urine and had skin issues related to moisture. R116 care area assessment (CAA) dated 7/18/25, identified that R116 was legally blind, had urine incontinence, and needed staff to assist with toileting, hygiene, and received nystatin (antifungal medication) to the groin twice a day to help with redness. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain respect and dignity for personal possessions for 1 of 1 residents (R140) reviewed who had personal property missing.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide assistance with grooming for 2 of 3 residents (R71, R177) reviewed for activities of daily living (ADLs).

Inspectors wroteBased on interview and document review, the facility failed to identify, monitor, and comprehensively assess for dehydration and significant weight loss for 1of 3 residents (R1) reviewed for change of condition. The facility's failures resulted in harm for R1 who had a 20 pound weight loss in 18 days and was subsequently admitted to the hospital for dehydration, acute renal failure, and later died.

Inspectors wroteBased on interview and document review the facility failed to follow the physician order to notify the medical provider of weight changes for 1 of 3 (R1) residents reviewed for change of condition.

Inspectors wroteBased on interview and document review the facility failed to ensure a comprehensive care plan was developed within the required timeline for 1 of 3 residents (R1) reviewed for change of condition.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure resident wheelchairs were kept in a clean and sanitary manner to promote resident well-being for 1 of 2 residents, (R17), observed for positioning.

Inspectors wroteBased on interview and document review, the facility failed to ensure a comprehensive, person-centered care plan was developed and readily available to promote acceptable pain management for 1 of 4 residents (R199) reviewed for care planning.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide adaptive supports or assistive devices to ensure upright positioning for 1 of 2 residents, (R17), reviewed for positioning. In addition, the facility failed to ensure medications were administered per physician's order for 1 of 2 residents (R480) reviewed for respiratory care.

Inspectors wroteBased on observations, interviews and document review, the facility failed to coordinate with dialysis, the nephrologist, and the primary physician when dialysis was discontinued for 1 of 1 resident (R102). This resulted in the potential for complications when R102 continued to maintain his dialysis central line with no routine dressing changes to prevent infection and continued on phosphorus binding medication, renal diet, and fluid restrictions.

Inspectors wroteBased on observation, interview, and document review, the facility failed to monitor orthostatic blood pressures with the use of an antipsychotic medication for 1 of 5 residents (R134) reviewed for antipsychotic medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 5 residents (R88) reviewed for immunizations was provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s).

Inspectors wroteBased on interview and document review, the facility failed to administer insulin according to the physician's orders for 1 of 3 residents (R1) reviewed for insulin administration.

Inspectors wroteBased on interview and document review, the facility failed to submit accurate and/or complete data for staffing information based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 4), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide a safe and sanitary environment. This had the potential to affect all 186 residents. During observations in the facility kitchen on 01/22/24 at 11:18 a.m., seven of fourteen exhaust hood filter panels were noted to have areas of one quarter to one-inch-thick grease imbedded with dust hanging over a double convection oven, a stationary kettle filled with water and no lid as well as a 2-burner natural gas stock pot range. When interviewed on 1/22/24 at 11:30 a.m., the dietary manager (DM) stated cleaning of the exhaust hood filter panels was done monthly or when needed by maintenance and provided a document entitled Main Kitchen Hood Cleaning 2023 with staff initials and last dated 12/19/23. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal hygiene care (i.e., nail care, shaving) was provided for 2 of 3 residents (R55 and R101) reviewed for activities of daily living (ADLs) and who was dependent on staff for their daily care and grooming needs.

Inspectors wroteBased on oberservation, interview and document review, the facility failed to ensure medication carts were properly secured for 2 of 4 medication carts located outside of the locked unit.