Bethesda Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of the Gradual Dose Reduction (GDR) document, and policy review, the facility failed to ensure a GDR was acknowledged and signed by the physician for one resident (#72) of five residents reviewed for unnecessary medications. The facility census was 82.Findings include:Review of Resident #72's medical record revealed an admission date of 04/26/24. Diagnoses included schizoaffective disorder, Chronic Obstructive Pulmonary Disease (COPD), history of pulmonary embolism, hypertension, depression, anxiety, and hyperlipidemia.Review of Resident #72's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of zero. Further review revealed Resident #72 was on an antipsychotic, antianxiety, antidepressant, anticoagulant, and anticonvulsant medication.Review of Resident #72's care plan dated 02/02/26 revealed Resident #72 utilized psychotropic medications related 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure a compreshensive care plan was completed including the use of oxygen therapy for one resident (#15) of three residents reviewed for oxygen. The facility census was 82. Findings include:Review of Resident #15's medical record revealed an admission date of 11/14/24. Diagnoses included acute respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), heart failure, hypertension, Type Two Diabetes Mellitus, and generalized anxiety disorder. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of seven. Further review of the MDS assessment revealed Resident #15 did not require the use of oxygen therapy. Review of Resident #15's care plans dated 03/26/26, 01/02/26, 10/09/25, and 09/29/25 revealed oxygen therapy was not included in the care plan. Review of Resident #15'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 medical record review, observation, staff interview, family interview, and policy review, the facility failed to ensure Activities of Daily Living (ADL) care was provided for dependent residents. This affected two residents, (#54 and #63) of three residents reviewed for ADL care. The facility census was 82. Findings include: 1.Review of Resident #63's medical record revealed an admission date of 08/12/24. Diagnoses included hypertensive chronic kidney disease, hypertension, dementia without behavioral disturbance, muscle weakness, and aortic ectasia. Review of Resident #63's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 required supervision or touching assistance for personal hygiene and partial or moderate assistance for showering and bathing. Review of Resident #63's care plan dated 01/14/26 revealed Resident #63 had a self-care deficit related to weakness and cognitive impairment with interventions that included for staff to assist with ADL's as needed and to report…

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 medical record reviews, review of an Emergency Medical Service (EMS) run report, staff and resident interviews, and review of facility policies, the facility failed to ensure follow up care was provided when skin breakdown was noted, failed to document skilled assessments, vital signs, and failed to notify the physician regarding a change of condition. The facility also failed to implement physician orders following an office visit. This affected two (Residents #77 and #91) of two residents reviewed for quality of care. The facility census was 82.Findings include:1.Review of the closed medical record for Resident #91revealed an admission on [DATE] and a discharge date of [DATE]. Diagnoses included Parkinsons Disease, essential hypertension, and dorsalgia. Further review of the medical record revealed no care plan or Minimum Data Set (MDS) had been completed due to time of admission and discharge. Review of the nurse progress notes revealed Resident #91 arrived at the facility on [DATE] from the hospital…

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 observation, resident interview, staff interview, record review, and review of facility policy, the facility failed to ensure implementation of physician-ordered pressure ulcer prevention interventions for one (Resident #7) of two reviewed for pressure ulcer. The facility census was 82.Findings Include: Review of the medical record for Resident #7 revealed an admission date of 12/09/25 with multiple diagnoses, including peripheral vascular disease, congestive heart failure, chronic obstructive pulmonary disease, and generalized weakness.Review of Resident #7's most recent quarterly Minimum Data Set (MDS) assessment, dated 02/16/26, revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Further review revealed Resident #7 required assistance with all activities of daily living, including bed mobility and repositioning.Review of the care plan dated 02/25/26 revealed the resident was at risk for impaired skin integrity with an intervention to utilize offloading boots while in bed.Review of Resident #7's medical record revealed…

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, staff interview, resident interview, medical record review, and review of facility policy, the facility failed to ensure orders for supplemental oxygen were in place for one residents (#15). This affected one residents (#15) of four residents reviewed for respiratory care. The facility census was 82.Findings Include: Review of Resident #15's medical record revealed an admission date of 11/14/24. Diagnoses included acute respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), heart failure, hypertension, type two diabetes mellitus, and generalized anxiety disorder. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of seven. Further review of the MDS assessment revealed Resident #15 did not require the use of oxygen therapy. Review of Resident #15's care plans dated 03/26/26, 01/02/26, 10/09/25, and 09/29/25 revealed oxygen therapy…

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 medical record review, interview, and review of the facility policy, the facility failed to ensure a dialysis port was monitored. This affected one (#4) of one resident reviewed for dialysis. The facility census was 82.Findings include:Review of the medical record for Resident #4 revealed an admission on [DATE]. Diagnoses included chronic kidney disease, stage four, Type Two Diabetes Mellitus, and chronic respiratory failure with hypoxia. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively impaired. Further review of the MDS revealed Resident #4 received dialysis. Review of the care plan dated 01/29/26 revealed Resident #4 needed resident care. Interventions included dialysis port in right chest. Further review of the care plan revealed Resident #4 received dialysis in-house. Interventions included monitor, documenting, and reporting any signs and symptoms to access site such as redness, swelling, warmth, or drainage. Review of the physicians' orders revealed…

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 Self-Reported Incident review, medical record review, and staff interview, the facility failed to ensure medications documentation was completed accurately for one (Resident #10). This had the potential to affect 18 residents (#4, #5, #10, #25, #27, #29, #31, #36, #37, #41, #50, #56, #57, #58, #60, #65, #68, #70) the facility identified as receiving opioid medication in the facility. The census was 82. Findings Include:Review of Resident #10's medical record revealed an admission date of 06/21/25. Diagnosis included congestive heart failure, end stage heart failure, Diabetes Mellitus Type II, and chronic obstructive pulmonary disease. Review of Resident #10's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had an intact cognitionReview of Resident #10's most recent care plan revealed she had a potential for alteration in comfort related to the disease process. interventions included educating the resident to request pain medication before her pain became severe.Review of Resident…

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 medical record review and staff interview, the facility failed to ensure resident code status orders accurately reflected their wishes as documented in their Advance Directives Form. This affected one resident (#40) of three residents (#33, #40, and #68) reviewed for code status. The facility census was 75.Findings Include:Review of the medical record for Resident #40 revealed an admission date of 07/23/25. Diagnoses included local infection of the skin and subcutaneous tissue, sepsis, bloodstream infection due to central venous catheter, cellulitis of left lower limb, morbid obesity, type two diabetes mellitus (DM2), disorder of vein, hypertension, tubulointerstitial nephritis, thrombocytopenia, streptococcus, non-pressure chronic ulcer of skin, disorder of arteries and arterioles, nonrheumatic mitral valve insufficiency, chronic lymphocytic leukemia of b-cell type, disorder of brain, chronic ischemic heart disease, pneumonia, viral hepatitis, stage three chronic kidney disease, dependence on renal dialysis, heart disease, glomerular disorders, anemia, lymphedema, acute…

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 medical record review and staff interview, the facility failed to ensure resident care plans accurately documented their code status. This affected one resident (#40) of three residents (#33, #40, and #68) reviewed for care planning. The facility census was 75.Findings Include:Review of the medical record for Resident #40 revealed an admission date of [DATE]. Diagnoses included local infection of the skin and subcutaneous tissue, sepsis, bloodstream infection due to central venous catheter, cellulitis of left lower limb, morbid obesity, type two diabetes mellitus (DM2), disorder of vein, hypertension, tubulointerstitial nephritis, thrombocytopenia, streptococcus, non-pressure chronic ulcer of skin, disorder of arteries and arterioles, nonrheumatic mitral valve insufficiency, chronic lymphocytic leukemia of b-cell type, disorder of brain, chronic ischemic heart disease, pneumonia, viral hepatitis, stage three chronic kidney disease, dependence on renal dialysis, heart disease, glomerular disorders,…

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 observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure routine medications were supplied to residents. This affected one resident (#40) of three residents (#33, #40, and #77) reviewed for pharmacy services. The facility census was 75.Findings Include:Review of the medical record for Resident #40 revealed an admission date of 07/23/25. Diagnoses included local infection of the skin and subcutaneous tissue, sepsis, bloodstream infection due to central venous catheter, cellulitis of left lower limb, morbid obesity, type two diabetes mellitus (DM2), disorder of vein, hypertension, tubulointerstitial nephritis, thrombocytopenia, streptococcus, non-pressure chronic ulcer of skin, disorder of arteries and arterioles, nonrheumatic mitral valve insufficiency, chronic lymphocytic leukemia of b-cell type, disorder of brain, chronic ischemic heart disease, pneumonia, viral hepatitis, stage three chronic kidney disease, dependence on renal dialysis, heart disease, glomerular disorders, anemia, lymphedema, acute kidney failure,…

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, staff interview, and facility policy review, the facility failed to ensure injectable medication was dated and labeled. This affected two residents (#23 and #42) identified by the facility as being prescribed injectable medication and residing on the 100-hall. The facility census was 75. Findings Include:Observation on [DATE] at 9:49 A.M. of the medication storage cart for the 100-hall with Licensed Practical Nurse (LPN) #175 revealed a Lantus SoloStar Pen insulin glargine (a type of long-acting insulin), 100 units per milliliter (units/mL), with approximately 60 of 300 units remaining, with a manufacturers date of [DATE], that was unlabeled with the date it was opened or the date it expired.Interview at the time of observation with LPN #175 verified the Lantus SoloStar Pen was unlabeled with the date it was opened or the date it expired.Review of the medication supplier guidelines titled, Medications with Shortened Expiration Dates, dated [DATE], Lantus Insulin glargine SoloStar pens…

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 medical record review, observation, staff interview, and policy review, the facility failed to ensure an effective infection prevention program was followed. This affected one resident (#26) of three reviewed for infection control related to wound care. The facility census was 75.Findings Include:Review of the medical record for Resident #26 revealed and admission date of 04/15/25. Diagnoses included cerebral infarction, benign prostatic hyperplasia (BPH), Barrett's esophagus, diverticulosis of large intestine without perforation, gastric ulcer, gastrointestinal (GI) hemorrhage, diaphragmatic hernia without obstruction or gangrene, hyperlipidemia, atrial fibrillation (a. fib), sick sinus syndrome, vertebra-basilar artery syndrome, neoplasm of uncertain behavior of colon, unspecified dementia, major depressive disorder, atherosclerotic heart disease of native coronary artery, gastroesophageal reflux disease (GERD), hemiplegia and hemiparesis, insomnia, depression, presence of cardiac pacemaker, presence of prosthetic heart valve, other nonspecific abnormal finding of lung…

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 employee file review, staff interview and review of facility policy, the facility failed to ensure State Tested Nursing Assistants (STNAs) had evaluations completed as required. This had the potential to affect all 68 residents residing in the facility. The facility census was 68. Findings Include: Review of the employee file for State Tested Nursing Assistant (STNA) #555 revealed a hire date of 11/11/22. No annual performance evaluations were found. Review of the employee file for STNA #557 revealed a hire date of 12/18/23. A 90 day performance evaluation was not found. Interview on 05/30/24 at 8:57 A.M. with the Administrator verified State Tested Nursing Assistant (STNA) #555 did not have an annual evaluation completed and STNA #557 did not have her 90 day evaluation completed. He stated he would have the Director of Nursing (DON) follow-up to make sure the evaluations were not somewhere else and not yet put into the file. Interview on 05/30/24 at 1:28 P.M. with the DON verified the evaluations for STNAs #555 and #557 were not completed. Review of the facility policy…

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 observation, staff interview, census list review, and policy review, the facility failed to ensure the flooring was maintained in a clean and appropriate condition. This affected fifteen (#2, #6, #9, #15, #25, #43, #45, #49, #56, #58, #60, #61, #62, #69, and #70) residents in the memory care unit. The census was 68. Findings include: Observation on 05/28/24 at 8:50 A.M., of flooring the hallway near the nurses station through the dining room revealed irregular areas of sticky yellowish residue on the linoleum floor. The affected area was sticky and covered with dust and debris. Staff, residents, and visitors were observed walking through the affected areas. Interview on 05/28/24 at 10:55 A.M., with Licensed Practical Nurse (LPN) #531 verified the floor was always sticky and does not come up. The dirt from the carpet or shoes gets stuck to the sticky areas of the floor, even with daily mopping. Interview on 05/28/24 at 11:21 A.M., with Housekeeping #524 verified the linoleum flooring had sticky areas that maybe from old wax residue. Housekeeping #524 reported the flooring…

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, resident interview, staff interview medical record review and review of facility policy, the facility failed to ensure resident preferences of room temperatures were honored. This affected two (#39 and #40) of three residents reviewed for choices. The facility census was 68. Findings Include: 1. Review of Resident #39's medical record revealed an admission date of 05/09/24. Diagnoses included type II diabetes, emphysema, chronic obstructive pulmonary disease, morbid obesity, and depression. Review of Resident #39's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #39 was cognitively intact. Resident #39 required limited assistance for transfers and two person physical assistance with toilet use. Resident #39 displayed no behaviors during the review period. Review of Resident #39's care plan, revised 05/09/24, revealed support and interventions for self-care deficit, altered nutrition, discharge plan for a short term…

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 medical record review, observation, resident interview, staff interview and review of the facility and review of facility policy the facility failed to ensure appropriate and timely care and services to assist with hearing. This affected one (#53) of three residents reviewed for hearing. The facility census was 68. Findings include: Review of the medical record for Resident #53 revealed an admission date of 08/26/22. Diagnoses included dementia, type II diabetes mellitus, morbid obesity, depression and hypertension. Review of the annual Minimum Data Set (MDS) assessment, dated 04/11/24, revealed Resident #53 had moderate cognitive impairment, and had highly impaired hearing with no hearing aid use. Resident #53 was usually understood and usually understood others. Review of the care plan, dated 09/07/22, revealed Resident #53 had maximum hearing difficulty. Interventions included to ask yes and no questions, decrease background noise, face resident when speaking, repeat phrases resident misunderstood, allow time for the resident to respond, and to refer for audiology…

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 medical record review, staff interview and review of facility policy, the facility failed to complete neurology checks on a resident with an unwitnessed fall per facility policy. This affected one (#29) of one resident reviewed for falls. The facility census was 68. Findings include: Review of the medical record for Resident #29 revealed an admission date of 09/16/22. Diagnoses included right femur fracture. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #29 was cognitively intact. Resident #29 had one fall since the last comprehensive assessment, resulting in no injury. Review of a nursing progress note, dated 05/23/24 at 7:15 A.M., revealed Resident #29 had an unwitnessed fall. Review of the current care plan revealed, following Resident #29's fall on 05/23/24, a new intervention was initiated to have the resident in the common area after she gets up for more supervision. Further review of the medical record revealed no evidence neurology checks were completed…

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 observation, staff interview, and policy review the facility failed to ensure portable oxygen tanks were sufficiently supplied with available oxygen for resident use. This affected one resident (#267) reviewed for oxygen use. The facility identified 12 residents who were on oxygen therapy. The facility census was 68. Findings include: Review of the medical record for Resident #267 revealed an admission date of 05/06/24 with diagnoses of chronic respiratory failure and chronic obstructive pulmonary disease (COPD). Review of the admission Minimum Data Set (MDS) assessment, dated 05/10/24, revealed Resident #267 was cognitively impaired and required the use of oxygen. Review of the current physician orders revealed Resident #267 was ordered oxygen two to four liters per nasal cannula to maintain an oxygen reading of 90% or above. Review of the care plan, dated 05/06/24, revealed Resident #267 was care planned for respiratory disorders with chronic respiratory failure. Interventions included use of oxygen as ordered. Review of the Medication Administration Record (MAR) for May…

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 medical record review, observation, resident interview, staff interview and review of facility policy, the facility failed to maintain accurate physician orders and failed to accurately assess a dialysis access site. This affected one (#30) of one resident reviewed for dialysis. The facility identified six residents who received dialysis. The facility census was 68. Findings include: Review of the medical record for Resident #30 revealed an admission date of 03/22/17. Diagnoses included end stage renal disease with a dependence on renal dialysis, type II diabetes mellitus, major depressive disorder, primary glaucoma left and right eyes, legal blindness, hyperparathyroidism and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was cognitively intact and received dialysis. Review of the care plan revealed Resident #30 had an alteration in health maintenance due to dialysis for end stage renal disease. Interventions included…

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 medical record review, observations, staff interview and review of the facility policy, the facility failed to ensure timely psychiatric follow-up for a resident experiencing an exacerbation of mood symptoms. This affected one (#33) of one residents reviewed for behavioral services. The facility census was 68. Findings include: Review of the medical record for Resident #33 revealed an original admission date of 04/05/20 and a readmission date of 02/16/24. Diagnoses included Parkinson's disease, dementia, morbid obesity, delusional disorders, heart failure, major depressive disorder, anxiety disorder, visual hallucinations, bipolar affective disorder and bipolar II disorder. Review of the annual Minimum Data Set (MDS) assessment, dated 04/23/24, revealed Resident #33 was cognitively intact with no functional impairment with a walker and wheelchair used for mobility. Resident #33 was independent with eating, oral care, and toilet hygiene, moderate assistance with bathing and personal hygiene, and maximal assistance with dressing. Active diagnosis included non Alzheimer'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 observations of medication storage, medical record review, staff interview, review of the manufacturer's recommendations and policy reviews, the facility failed to ensure insulins were dated when opened and failed to ensure expired insulins were discarded. This affected three (#10, #20, and #267) of three residents medications observed for medication storage. The facility census was 68. Findings include: 1. Review of the medical record for Resident #267 revealed an admission date of [DATE], with diagnosis of diabetes mellitus type II. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #267 revealed he was cognitively impaired and required the use of insulin. Review of the current physician orders from [DATE] for Resident #267 revealed jardiance 10 milligrams (mg) and blood sugar monitoring before meals and at bedtime with Lispro insulin per sliding scale coverage 151-200=two units, 201-250=four units, 251-300=six units, 301-350=eight units, 351-400=10 units, greater than…

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, resident interview, staff interview, and review of the policy, the facility failed to ensure used soiled bed pans were stored appropriately in a shared bathroom. This affected one (#38) of one resident reviewed for used bed pan storage in a shared bathroom. The facility census was 68. Findings include: Review of the medical record for Resident #38 revealed an admission date of 02/22/24, with diagnoses of chronic obstructive pulmonary disease (COPD), diabetes mellitus type II, high blood pressure, dependence on oxygen, anxiety, and schizoaffective disorder, and bipolar disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #38 revealed she is cognitively intact and is independent with transfers, ambulating, and requires moderate assistance with toileting. Review of the care plan dated 02/26/24 for Resident #38 revealed she is care planned for assistance with toileting. Interview on 05/28/24 at 8:58 A.M., with Resident #38 stated my roommate only uses…

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 resident and staff interviews, review of a resident concern form, and review of facility policy, the facility failed to ensure residents were treated with dignity and respect. This affected three (Residents #21, #28, and #42) of three reviewed for dignity. The facility census was 63. Findings include: 1. Review of Resident #21's medical record revealed an admission date of 12/21/22. Diagnoses included chronic obstructive pulmonary disease (COPD), emphysema, type II diabetes, history of falling, muscle weakness, obesity, displaced bimalleolar fracture of left lower leg, subsequent encounter for closed fracture with routine healing, dependence on supplemental oxygen, congestive heart failure (CHF), chronic kidney disease, depression, osteoporosis, atrial fibrillation, hypertension, Alzheimer's disease, and fibromyalgia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact and required extensive assistance with bed mobility, dressing, and…

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 medical record review, observation, and interview, the facility failed to ensure bilateral grab bars were in place on a resident's bed per physician orders. This affected one (Resident #25) of two residents reviewed for position and mobility. The facility census was 63. Findings include: Review of the medical record revealed Resident #25 had an admission date of 07/12/13. Diagnoses included Alzheimer's disease, dementia, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had impaired cognition. Resident #25 required the extensive assistance of one staff for bed mobility and transfers. Review of a physician order dated 05/04/22 revealed the resident had an order for bilateral grab/transfer bars to the bed to facilitate independence. Review of the most recent physical device data collection evaluation dated 04/18/23 revealed the left and right grab bar on the bed assisted the resident with independent repositioning in bed. Observations on…

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 Beneficiary Protection Notification Review and staff interview, the facility failed to ensure Advanced Beneficiary of Non-Coverage (ABN) notifications were issued to residents who remained in the facility following termination of Medicare Part A services. This affected two (Residents #21 and #40) of three residents reviewed for beneficiary notice protection. The facility census was 63. Findings include: 1. Review of Resident #21's Beneficiary Protection Notification revealed the resident's last covered day of Medicare Part A services was 03/03/23. The facility issued the Notice of Medicare Non-Coverage (NOMNC) on 02/28/23. A Advanced Beneficiary of Non-Coverage (ABN) was not issued by the facility, with a notation Resident #21 remained in the facility under Medicaid. 2. Review of Resident #40's Beneficiary Protection Notification revealed the resident's last covered day of Medicare Part A services was 04/07/23. The facility issued the NOMNC on 04/05/23. An ABN was not issued by the facility, with a notation Resident #40 remained in the facility under Medicaid. Interview on…

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 medical record review, observation, staff interview, resident interview, and review of facility policy, the facility failed to ensure residents were provided an environment with comfortable sound levels. This affected one (Resident #22) of three reviewed for comfortable sound levels. The facility census was 63. Findings include: Review of Resident #22's medical record revealed an admission date of 10/24/19. Diagnoses included type II diabetes, cognitive communication deficit, legally blind, history of lung cancer, history of skin cancer, history of bladder cancer, major depressive disorder, mild cognitive impairment, and hearing loss. Review of Resident #22's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating Resident #22 was moderately cognitively impaired. Resident #22 was independent or required set up only with all of his activities of daily living. Resident #22 had moderate difficulty with hearing. Resident #22 was able to make himself…

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 review of facility policy, the facility failed to provide care and services to potentially prevent additional and/or worsening pressure ulcers. This affected one (Resident #34) of two residents reviewed for pressure ulcers. The facility census was 63. Findings included: Review of the medical record for Resident #34 revealed an admission date of 01/18/23, diagnoses included heart failure, osteoarthritis, dementia, with mood disturbance, anxiety disorder, hypoxemia, iron deficiency anemia, hypertension, hearing loss, and diverticulosis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had impaired cognition, required the extensive assistance of two staff for bed mobility, transfers and toilet use, and the extensive assistance of one staff for walking, locomotion, dressing, and personal hygiene. Resident #34 used a wheelchair and walker for mobility. Resident #34 was occasionally incontinent of bowel and bladder, had no skin…

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 medical record review, observation, resident interview, staff interview and review of facility policy, the facility failed to ensure oxygen supplies were dated when initiated according to physician orders. This affected one resident (#42) of five residents reviewed for oxygen therapy. The facility census was 63. Findings include: Review of Resident #42's medical record revealed an admission date of 06/01/22. Diagnoses included congestive heart failure (CHF), type II diabetes, morbid obesity, osteoarthritis, anxiety disorder, major depressive disorder, hypertension. Review of Resident #42's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #42 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Resident #42 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #42 received oxygen therapy at the time of the review. Review of Resident #42's care plan revised 03/12/23 revealed supports and interventions for need…

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.