Bethesda Care Center

In the surveyor’s words

From the most serious findings on record at Bethesda Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Dec 13, 2024

  Based on review of electronic medical records, review of emergency medical squad report, review of hospital records, review of staff education, staff interviews, review of text message review of facility policies, and resident family interview, the facility failed to ensure Resident #76 received medications to prevent seizure activity and notify the physician of resident not receiving medications and having seizure activity. This resulted in Immediate Jeopardy and serious life-threatening harm on 11/14/24 when, as a result of not having his prescribed medications, Resident #76 subsequently experienced continual tonic-clonic seizures (also known as a grand mal seizure - a type of seizure characterized by a sudden stiffening of the body muscles [tonic phase] followed by rapid jerking… […]

• No harm, potential for more than minimal, widespreadF730May 30, 2024

  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. […]

• No harm, potential for more than minimal, widespreadF880Aug 25, 2022

  Based on observations, staff interviews, review of the facility's policy, and review of the Centers for Disease Control and Prevention (CDC) guidance and Centers for Medicare and Medicaid Services (CMS) online resource, the facility failed to ensure staff wore their masks properly while providing care and services to residents. This affected six residents (#10, #11, #12, #13, #14 and #15) and had the potential to affect all 64 residents residing in the facility. Findings include: Interview on 08/24/22 at 8:06 A.M. with the Administrator revealed the staff were currently required to wear a medical/surgical mask and eye protection throughout the facility. Observations on 08/24/22 between 8:36 A.M. and 9:24 A.M. […]

• No harm, potential for more than minimal, widespreadF880Jan 5, 2021

  Based on medical record review, observation, interview, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to implement procedures to potentially reduce the transmission of COVID-19, including 14-day quarantine and social distancing of new admissions specifically on the memory care unit and the use of recommended personal protective equipment (PPE) for any new admission. The facility did not have any current cases of COVID-19. This had the potential to affect all 59 residents of the facility. Findings include: 1. Review of the medical record revealed Resident #09 was admitted from a local hospital on [DATE]. […]

• No harm, potential for more than minimal, patternF641Apr 2, 2026

  Based on record review, staff interview, and facility policy review the facility failed to ensure the Minimum Data Set (MDS) was accurately coded. This affected four residents (#25, #31, #36 and #15) and had the potential to affect 13 residents the facility identified as receiving respiratory services at the facility. The facility census was 82.Findings included:1 - Review of Resident #25 revealed an admission date of 08/02/24. Diagnosis included chronic kidney disease, obstructive sleep apnea, chronic obstructive pulmonary disease, and obesity. Review of Resident #25's quarterly Minimum Data Set (MDS) dated [DATE] revealed she had an intact cognition. […]