Inspection Reports for Bethesda Rehab & Senior Care

The facility failed to ensure a medication administration error rate below 5 percent, with 3 errors out of 33 opportunities resulting in a 9.09% error rate affecting 2 of 4 residents reviewed. Errors involved incorrect medications administered to residents R2 and R5.

The complaint investigation was triggered by an allegation of abuse involving resident R1, who had discoloration under her left eye allegedly caused during ambulance transport. The facility did not report this allegation to the state agency. The investigation included interviews with the resident, family, facility staff, and the ambulance company. The facility concluded the incident was not abuse based on the resident's statements and ambulance investigation, but failed to report the allegation as required.

The facility failed to report an abuse allegation related to discoloration under R1's left eye, which was alleged to have occurred during ambulance transport. The facility's investigation concluded the incident was not intentional abuse, and the ambulance company found no incident during transport. However, the reportable abuse allegation was not submitted to the state agency as required.

The facility was found deficient in multiple areas including failure to obtain physician orders for medication self-administration, failure to refer residents for PASRR re-evaluation, inadequate nail care, improper pressure ulcer care, failure to follow fall care plans resulting in injury, improper respiratory care, inappropriate use and documentation of bed rails, medication errors exceeding 5%, failure to provide therapeutic diets and supplements as ordered, and lapses in infection prevention and control practices.

The complaint investigation found that R1 had nine fall incidents documented between 9/27/2024 and 11/8/2024. The resident had a history of falls and cognitive impairment. The facility had initially provided a 1:1 aide which was removed after two weeks, after which falls recurred. The resident sustained a three centimeter scalp laceration on 9/28/2024 requiring hospital treatment.

The facility failed to ensure adequate supervision and fall prevention for resident R1, who experienced nine repeated falls despite being identified as a high fall risk. The resident had severe cognitive impairment and sustained a scalp laceration requiring hospital treatment after one fall.

The investigation was complaint-driven due to multiple falls reported for resident R1, including two falls within 30 days. The complaint was substantiated as the facility failed to provide adequate supervision and use of gait belt during transfers, leading to injury.

The facility failed to utilize a gait belt during the transfer of a legally blind resident (R1) from toilet to wheelchair, leading to a fall and a comminuted left femur fracture requiring surgical repair. Interviews and record reviews confirmed inadequate supervision and failure to follow transfer protocols.

The investigation was complaint-driven based on reports from residents and staff about call light response delays, missed medication administration, and inadequate incontinence care. The complaint was substantiated with observations, interviews, and record reviews confirming the deficiencies.

The facility failed to monitor and respond to call lights in a timely manner for multiple residents, did not provide incontinence care for several dependent residents, failed to administer medications as ordered for one resident, and lacked sufficient nursing staff coverage to ensure adequate resident care and support. These issues potentially affected 20 residents on the three north unit.

The facility failed to ensure that residents dependent on staff assistance for ADLs received adequate grooming, showers, personal hygiene, and feeding assistance. Observations, interviews, and record reviews revealed multiple residents had not received proper care, including missed showers, inadequate feeding assistance, and poor hygiene.

The facility failed to ensure menus and individual food plans were followed for several residents, failed to provide a variety of entrees, and did not communicate menu changes or food substitutions to residents. Specific issues included residents not receiving milk as ordered, repetitive menus with excessive pasta, lack of coffee due to supply issues, and unnotified substitutions such as replacing Barbeque Chicken Sandwich with dry chicken breast. There was also a failure to maintain a Food Substitution Log as required.

The facility was found deficient in multiple areas including failure to serve residents meals simultaneously, inadequate language support for non-English speakers, improper care of residents with compression stockings and midline catheters, failure to maintain pressure ulcer prevention devices, insufficient supervision in dining areas, nutritional deficiencies including failure to provide ordered supplements and thickened liquids, improper care of feeding tubes, unsafe respiratory care practices, inadequate staffing impacting resident care and medication administration, failure to properly label and store medications, menu and food service deficiencies including serving cold and unpalatable food, and lapses in infection prevention and control practices.

The visit was complaint-related due to a fall incident involving resident R2. The complaint was substantiated as the facility failed to prevent the fall and injury. Resident R2 was found on the floor with a laceration on the right lower leg, requiring emergency room care and sutures.

The facility failed to ensure resident safety for one resident (R2) who fell and sustained a right leg laceration requiring emergency room treatment and sutures. The investigation revealed inadequate supervision and failure to properly assist the resident during care, contributing to the fall and injury.

The complaint investigation focused on residents' rights violations regarding food menu choices, improper involuntary discharge procedures, failure to provide bed hold policy, denial of resident return after hospitalization, and infection control failures related to COVID-19 cohorting.

The facility failed to ensure residents were given menus to choose their food, failed to implement involuntary discharge and bed hold policies properly for one resident (R3), failed to permit R3 to return after hospitalization, and failed to properly cohort COVID-positive residents, potentially exposing others to infection.

The complaint investigation focused on allegations of physical and mental abuse of residents R23, R24, and R42, including rough handling and rude behavior by staff. The investigation found substantiated abuse with actual harm to one resident and mental anguish to two others. The facility failed to conduct thorough investigations and timely reporting of abuse incidents to the state. Additional complaints involved infection control lapses, medication management, and COVID-19 testing and vaccination deficiencies.

The facility failed to protect residents from physical and mental abuse, failed to conduct thorough investigations and timely reporting of abuse incidents, failed to ensure proper respiratory care labeling, failed to maintain kitchen sanitation and food safety, failed to properly manage psychotropic medication orders, failed to conduct COVID-19 testing and vaccination documentation properly, and failed to implement infection prevention and control measures including sanitizing equipment between residents.

The complaint investigation revealed that resident R1 received Digoxin medication and a lab draw that were not ordered by the physician, and resident R2 was transferred improperly without a total body lift, resulting in a leg laceration requiring 25 sutures and hospital transfer.

The facility failed to ensure that only ordered medications were administered to residents, resulting in one resident receiving medication not prescribed by their physician. Additionally, the facility failed to follow proper transfer protocols for another resident, leading to a laceration requiring hospital treatment.