Bethesda Home of Aberdeen

Based 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 observed meal services. Findings include: 1. Observation on 3/10/26 at 8:35 a.m. in the dining room revealed the popcorn machine was sitting in the bar area. The machine had leftover popcorn kernels in…

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, 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. Findings include:1. Observation on 3/12/26 at 8:41 a.m. in the kitchen of chef P revealed he was serving breakfast from a steam table. He served ham and cheese egg scramble with a green-handled #12 scoop, and breakfast potatoes with a pair of tongs. There was a meal ticket printer that printed the residents' meal choices. Those meal tickets included the menu item, but not the serving sizes. 2. Review of the provider's menu and recipe binder…

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 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). Findings include:1. Review of resident 2's electronic medical record (EMR) revealed that she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), unspecified psychosis not due to a substance or known physiological condition, unspecified hallucinations, delusional disorder (false beliefs and distorted views of reality), dementia (a group of symptoms affecting memory, thinking, and social abilities), depression, and anxiety…

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 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).Findings include: 1. Review of resident 33's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. He was discharged to the hospital on [DATE]. His 11/4/25 discharge tracking MDS assessment was not transmitted to CMS. 2. Review of resident 43's EMR revealed she was admitted to the facility on [DATE]. She was discharged on 11/25/25 to her daughters' home. Resident 43's 11/25/25…

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, 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. Findings include:1. Observation and interview on 3/11/26 at 9:44 a.m. in the Morning Dove Lounge revealed that resident 2 was sitting in a recliner. She had her left leg pulled up towards her torso, and she appeared to be trying to adjust her gripper sock or the cuff of her pants. Her walker was in front of her. She was not wearing shoes. When asked how she was doing that day, she mumbled about there being a bum on or near her left foot. She was not easily understood. She put her left foot back down on the floor, reached forward, and continued to point and readjust her pant leg while talking about the bum. 2. Interview on 3/12/26 at 12:29 p.m. with certified nurse aide (CNA) K revealed that resident 2 often…

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, 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. Findings include: 1. Interview on 3/10/26 at 3:00 p.m. with resident 3 revealed he received insulin. He had a history of low blood sugar levels in the mornings. He mentioned that he did not feel any different when his blood sugar level was low. The staff usually gave him a glass of juice if his blood sugar was low. Sometimes, his blood sugar level got as low as 50 to 57 (milligrams per deciliter, mg/dL) in the mornings. 2. Review of resident 3's electronic medical record (EMR) revealed he had a diagnosis of Type 2 Diabetes Mellitus (a condition involving disruptions in how the body regulates…

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, 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. Findings include: 1. Observation and interview on 11/19/24 at 7:45 a.m. with chef M, chef H, and culinary services manager (CSM) D revealed: *Chef M was at the steam table serving breakfast to residents and stated chef H would have done the food temperatures this morning. *Chef H was by the ovens and the food prep area, and stated she forgot to take the food temperatures that morning. -The food temperature logs indicated food temperatures had not been documented that morning and chef H stated she would sometimes take the food temperatures but not log them and sometimes she would just forget to take the food temperatures. -She stated she should check the temperatures of the food coming out of oven and at the steam table. *CSM D told chef H to temp the next batch of food and log those temperatures. Chef H completed that task. 2. Record review and 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 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. Findings include: 1. Observation and interview on 11/19/24 at 9:42 a.m. with resident 288 in her room revealed: *She was short of breath, spoke softly, and was wearing oxygen nasal cannula tubing (tubing with nasal prongs) on her face. *There was an oxygen concentrator (a device that delivers concentrated oxygen) with a humidifier attached to it. The oxygen flow rate was set at 5 Liters (L) per minute. *A portable oxygen tank was on the back of her wheelchair. 2. Review of resident 288's electronic medical record (EMR) revealed: *Resident 288 had been admitted on [DATE] from home with continued hospice services. *Her diagnoses included malignant neoplasm of unspecified bronchus or lung, chronic obstructive pulmonary disease, chronic kidney disease, and other forms of dyspnea. *There was a…

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 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. Findings include: 1. Observation on 11/19/24 between 8:25 am and 9:02 a.m. with resident 288 in her room revealed: *At 8:25 a.m. registered nurse (RN) F started her nebulizer (neb) machine for the administration of her neb medication treatment and then left the room. -Resident 288 asked the surveyor to return when she completed that nebulizer treatment. *At 8:40 a.m. the nebulizer treatment was running and resident 288 was wearing a neb mask. *At 8:55 a.m. the nebulizer was still running and resident 288 was holding the mask in her hand. *At 9:02 a.m. RN F walked by resident 288's room and into room [ROOM NUMBER]. Resident 288's nebulizer was still running…

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 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. Findings include: 1. Review of resident 288's facility care plan revealed: *She had been admitted on [DATE]. *Her diagnoses included malignant neoplasm of unspecified bronchus or lung, chronic obstructive pulmonary disease, chronic kidney disease, and other forms of dyspnea. *[Resident 288] was admitted on hospice from home. *A focus area: Resident and family have opted for hospice benefits and comfort care only. *A goal: Will receive additional support from hospice. Have comfort and dignity maintained on [a] daily basis. *Interventions/Tasks: -Keep family and hospice involved in care planning and decision making as well as updated on any changes in conditions or orders. -Keep hospice staff…

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 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. Interview on 7/24/23 at 3:29 p.m. with culinary dining assistant I about the above observations revealed: *The south refrigerator was mainly used for…

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.