Carriage Hill Bethesda

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 8, 2022

  Based on observations, record review, and family and staff interviews, it was determined that the facility failed to have a system in place to: 1.) identify and address residents at risk for elopement to provide the appropriate interventions to keep them safe, 2.) ensure doors that opened into stairwells and that exited out of the building were appropriately used and monitored to keep residents safe, and 3.) prevent systematic disarming of alarm systems allowing cognitively impaired residents access to exit doors. These deficient practices resulted in 2 residents (Resident #9 and Resident #10) leaving the facility unsupervised and undetected and had the potential to affect all vulnerable residents that require interventions for increased supervision and monitoring for safety. […]

• No harm, potential for more than minimal, widespreadF640Jan 17, 2025

  Based on record review and interview, it was determined that the facility failed to complete and transmit the Minimum Data Set (MDS) assessments. This was evident for 27 (Residents #4, #6, #9, #11, #22, #23, #30, #32 #46, #62, #64, #65, #71, #72, #76, #78, #81, #87, #91, #93, #94, #95, #96, #99, #101, #102 and #109) of 33 residents reviewed for resident assessments during the annual survey. The findings include: Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. […]

• No harm, potential for more than minimal, widespreadF921Jan 17, 2025

  Based on observations and interviews it was determined that the facility failed to ensure a safe environment. This was found to be evident during random observations conducted of the facility's environment during the recertification survey. This deficient practice has the potential to affect all Residents. The findings include: According to the Centers of Medicare and Medicaid Services the acceptable water temperature for nursing homes and facilities serving residents should be thermostatically controlled to a maximum of 120 degrees Fahrenheit at the fixture, ensuring hot water is at least 100 degrees Fahrenheit. […]

• No harm, potential for more than minimal, widespreadF835Aug 8, 2022

  Based on review of a complaint, review of administrative and clinical documentation, and interviews with facility staff, it was determined that the facility failed to keep a cognitively impaired resident with exit-seeking behaviors from exiting the building on 09/05/21 and failed to investigate this incident to determine how the resident exited the building. As a result, a second resident was found to have exited the building on 6/25/22 and was found outside in the building's back parking lot. This was found to be evident for two of 17 residents reviewed (Resident #9 and #10) during an Infection Control and Complaint survey conducted at the facility. […]

• No harm, potential for more than minimal, widespreadF838Aug 8, 2022

  Based on review of facility records and an interview with staff, it was determined the facility failed to provide revise and document an accurate up-to-date facility-wide assessment annually. This was identified during an extended survey. This has the potential to affect all residents within the facility. The findings include: A facility-wide assessment is conducted to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The assessment is to include the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. […]