Bethesda Southgate

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF880Jul 18, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF550May 1, 2025

  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… […]

• No harm, potential for more than minimal, isolatedF554Jul 18, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF623Jul 18, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF686Jul 18, 2024

  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. […]