Bethesda Southgate

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two residents were free from derogatory and disrespectful remarks from staff members (Resident #1 and Resident #2). The sample was three. The census was 106 with 79 in certified beds. Review of the facility's Resident Rights and Responsibility Policy, dated 6/2022, showed the following: -Purpose: To provide an awareness to all staff of the rights and responsibilities of each resident; -Responsibility: It is the responsibility of all employees to know and to comply with this policy; -Policy: -The 1987 Nursing Home Reform Law requires that each nursing home provide care for its residents in a manner that promotes and enhances the quality of life for each resident, ensuring dignity, choice and self-determination; -During orientation and minimally, at annual in-services, all employees shall be fully informed of resident rights and responsibilities. Bethesda will not tolerate infringement of resident rights by any employee. Allegations of violations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to follow their infection control policy when staff failed to complete the annual one step of the employee tuberculosis (TB, a potentially serious infectious bacterial disease that mainly affects the lungs) screening tests for three employees. The census was 110 with 31 in state license beds. Review of the facility's Tuberculosis Screening and Testing of Employees and Volunteers, dated May 2024, showed the following: -Purpose: To establish guidelines for consistency in tuberculosis screening and testing for new employees and volunteers and annual testing and assessment for existing employees and volunteers. -Scope: Level I policy affecting all employees and all volunteers who work ten or more hours weekly in long term care communities which includes skilled nursing. -Responsibility: It is the responsibility of the Infection Preventionist/Employee Health Nurse or designee to perform annual health screenings. -There was no documentation regarding an annual one step tuberculin skin tests (TST). 1. Review of Staff Member A's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and policy review, the facility failed to ensure residents who self-administered medications had a self-administration of medications assessment, a physician's order, and a care plan completed for one of one resident (Resident (R) 134) reviewed for self-administration of medications out of a sample of 23 residents. Failure to assess and care plan residents for self-administration of medications increases the potential of medication errors for residents. Findings include: During medication pass observation with Licensed Practical Nurse (LPN) 1 on 07/07/24 at 11:56 AM, she placed one tablet of ferrous sulfate 325 milligrams (mg) into a clear medication cup. LPN1 stated that was all R134 received at this time. LPN1 then entered R134's bedroom, where R134 was sitting up in her wheelchair with the overbed table in front of her. LPN1 placed the medication cup on the table and told R134 that the medication was her iron pill. Then LPN1 walked out of the room. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure one of three residents and their representatives (Resident (R) 1) reviewed for facility initiated emergent hospital transfers were provided with written transfer notice that contained all required information. This failure has the potential to affect the resident and/or the Resident Representatives (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of R1's untitled and undated face sheet provided by the facility revealed the resident was most recently readmitted to the facility on [DATE] with diagnoses which included intracranial hemorrhage, persistent vegetative state, and spastic hemiplegia. Review of R1's SNF-SBAR [Skilled Nursing Facility - Situation, Background, assessment, and Recommendation] document, dated 06/17/24 and provided by the facility, revealed . NP [nurse practitioner] came in and this nurse had reported…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents' pressure ulcers were assessed and received the necessary treatment and services to promote healing and to prevent worsening of pressure ulcers for one of three residents (Resident (R) 1) reviewed for pressure out of 23 sampled residents. R1 had a history of a pressure ulcer on her left pinky finger healing and reopening. The facility failed to ensure measures were taken to prevent the pressure ulcer from reopening and worsening from a stage 2 pressure ulcer to a stage 3 pressure ulcer. Additionally, the facility started treatment on the pressure ulcer without notifying and obtaining a physician's order. These failures placed R1 at risk for further worsening of the pressure ulcer. Findings include: Review of R1's untitled and undated face sheet provided by the facility revealed the resident was most recently readmitted to the facility on [DATE] with diagnoses which included intracranial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure safe water temperatures in residents' bathrooms/personal sinks were maintained for two of 23 sampled residents (Resident (R) 51 and R17). The residents' bathroom sink hot water temperatures were greater than 120 degrees Fahrenheit (F). This failure placed both residents at risk for skin irritation, redness, pain, and burns. Findings include: 1. Review of R51's untitled and undated face sheet, provided by the facility, revealed the resident was most admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and dementia. Review of R51's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/06/24, provided by the facility, revealed the facility assessed a Brief Interview of Mental Status (BIMS) score could not be obtained on the resident. The facility assessed R51 had short and long term memory problems, and was severely cognitively impaired when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, document review, and facility policy review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice related to the transcription and following of physician's orders for 1 (Resident #11) of 6 residents reviewed for medication regimen review and related to following physician's orders regarding fluid restrictions for 1 (Resident #36) of 1 resident reviewed for dialysis. Findings included: A review of a facility policy titled, Bethesda Long Term Care Nursing Practices Policy and Procedure, updated 09/2022, specified It is the responsibility of the licensed nurse and the CMT [Certified Medication Technician] to understand and comply with this procedure, it is the responsibility of the Nurse Manager to maintain, enforce and monitor the procedure. The policy further indicated, Telephone and verbal orders should be documented in the resident's electronic medical record then read back to the ordering…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and facility policy review, the facility failed to ensure the oxygen nasal canula was contained when not in use for 1 (Resident #41) of 2 sampled residents receiving oxygen therapy. Findings included: A review of a facility policy titled, Oxygen Administration, revised 02/2019, revealed, Purpose: To provide guidelines for oxygen administration. Policy: A physician order is required to administer oxygen. The order should include the administrative device, liter flow and the parameters for use. Practice: 1. Oxygen should be ordered by the physician. The order should indicate the administrative device, the liters per minute, frequency and indications for use. A review of Resident #41's Resident Information document revealed the resident had diagnoses that included acute posthemorrhagic anemia (loss of a large amount of blood in a short period of time), dementia, and cerebral infarction (stroke). A review of Resident #41's quarterly Minimum Data Set (MDS), dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to allow an immediate family member to act on behalf of a resident in order to support the resident in decision-making for medical and financial matters. In addition, the facility failed to pursue a legal representative or court-appointed guardian after the immediate family member's rights were revoked by the facility and after it was determined that the resident was not capable of making their own medical and financial decisions (Resident #85). The facility census was 137 with 99 residents in certified beds. Review of the facility's Resident Handbook, revised [DATE], showed the following: -Resident's representative: The person designed in writing by the resident or resident's legal representative to receive communication on behalf of resident and to make health care or financial decisions, or both, on behalf of the resident. The resident's representative may be the resident's legal representative and/or the resident's immediate family member; -Surrogate:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to check the Nurse Aide Registry to ensure new employees did not have a Federal Indicator for abuse or neglect (which means the individual cannot work in a certified long-term care facility without a good cause waiver) prior to hire for two out of eight sampled employees. The census was 137 with 99 in certified beds. 1. Review of Floor Finisher A's employee record, showed the following: -Date of hire: 9/10/18; -No record of a Federal Indicator check. 2. Review of Activity Assistant B's employee record, showed the following: -Date of hire: 1/14/19; -No record of a Federal Indicator check. 3. During an interview on 9/24/19 at 4:00 P.M., Human Resources confirmed that the two employees did not have a federal indicator check completed. It was not included in their employee file. All new employees are required to have a federal indicator check completed. 4. During an interview on 9/24/19 at 5:15 P.M., the administrator said she would expect new employees to have a federal indicator check completed.

Based on observation, interview and record review, the facility failed to ensure services provided or arranged by the facility, meet professional standards of quality by failing to clarify medication orders, for one of 18 sampled residents (Resident #191). The census was 137 with 99 in certified beds. Review of Resident #191's care plan, dated 9/20/19, showed: -Resident admitted for rehabilitation services following a hospitalization. Diagnoses included stroke, left sided weakness. Resident takes significant medication to help prevent blood clots which may cause bruising, or to bleed more easily. Please tell the nurse if you see any bruising or active bleeding. If resident complains of light headedness, or dizziness or appears to be light headed, or dizzy please tell the nurse. Review of the resident's physician orders sheet, showed an order dated 9/19/19 for Hydralazine (used to treat high blood pressure), 25 milligrams (mg), every 6 hours. Next to the order a note, *At home, patient was taking the medication with the following details: Special instructions, hold if systolic blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility staff failed to complete a comprehensive discharge summary for one of three closed record sampled residents (Resident #86). The census was 137 with 99 in certified beds. Review of Resident #86's closed medical record, showed the resident discharged to the community on 6/22/19. Staff did not complete a discharge summary, which would include a final summary of the resident's status, a reconciliation of all pre and post discharge medications and a post-discharge plan of care. During interviews on 9/24/19 at 6:37 P.M. and 9/25/19 at 9:37 A.M., the Director of Nursing (DON) said there is not a nursing discharge summary in the resident's file. It is the nurse's responsibility to ensure that the discharge packet is completed. After the nurse gives the information to the resident and places it in the chart, medical records then reviews it to ensure that it is complete.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good personal hygiene by failing to follow the perineal care (cleansing from the front of the hips, between the legs and buttocks) policy and ensure appropriate perineal care was provided for two of three observations (Residents #6 and #42). The census was 137 with 99 in certified beds. Review of the facility's perineal care policy, revised 11/2017, showed: -Purpose: To provide guidelines for performing perineal care; -Responsibility: it is the responsibility of all nursing staff to follow this policy; -Policy: Perineal care is to be done at least daily and as needed for incontinence for residents who are unable to perform self-care. Perineal care is done to cleanse the perineum (groin) to prevent growth of bacteria, prevent skin breakdown and promote good personal hygiene; -Perineal care: always work from the dirtiest to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident received treatment and care in accordance with professional standards of practice when the facility failed to ensure the resident's physician's order for a hospice consult was followed timely (Resident #85). In addition, incorrect information regarding the resident being a ward of the state provided to the hospice company resulted in the resident's hospice consult being declined. The facility failed to clarify the error with the hospice company. This resulted in the resident not receiving hospice services, which are services provided above and beyond the services provided by the facility, to include additional care aides and nurses, chaplain services and bereavement services for the family for a year after the resident passes. The facility census was 137 with 99 residents in certified beds. Review of the facility's Resident Handbook, revised [DATE], showed the following: -Surrogate: A person identified from the Missouri statutes to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.