Bethesda Senior Care

Based on LPAs observations, facility has one fire extinguisher which was last serviced in 10/19/2022 which poses a potential health, safety or personal rights risk to persons in care.

Based on staff interview and record review, the licensee did not comply with the section cited above as staff ,S1, does not have active CPR/FIRST AID certification as required which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review and staff interview, it was found that resident, R1 medications, Losartan 25 mg/90 tablets- 1 tablet daily with start date 05/03/24 ( 2 extra tablets ) ,Mirtazapine 15mg/90 tablets- 1 tablet daily with start date 05/03/24 ( missing 3 tablets) , Buspirone, 5 mg/30 tablets, 1 tablet/2 times a day with start date 06/07/24 (10 tablets extra), which poses an immediate health, safety or personal rights risk to persons in care.

87211(a)(1)(D) -Reporting Requirement- Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse …. This requirement is not met as evidenced by; Based on the records reviewed, it has been determined that the facility did not report an incident where staff, S1 made inappropriate sexual conduct to staff, S2 on 05/31/23 which poses an immediate health and safety risks to residents in care.

87405- Administrator - Qualifications and Duties(d)(2)- Knowledge of and ability to conform to the applicable laws, rules and regulations….. This requirement is not met as evidenced by; Based on the records reviewed and interviews, it has been determined that the administrator did not report an incident where staff, S1 made inappropriate sexual conduct to staff, S2 on 05/31/23 which poses an immediate health and safety risks to residents in care.

During record review ,LPA observed that residents files for R1 and R2 missing LIC613 (Personal Rights) and Consent forms as required per regulation which poses/posed a potential health, safety or personal rights risk to persons in care.

LPA observed that LIC503-Health Screening for S2 was missing in S2's file, which poses a potential risks to residents in care for thier health and safety.

LPA found out that ,LIC501-Personal record form for S2, LIC508(Criminal Record Statement ) for S1 and S2 ,LIC9052 (Employee Rights) for S1 and S2 missing in staff's files. which poses a potential risks to residents in care for thier health and safety.

LPA observed that S1and S2 does not have training records on staff's files per above requirement which poses/posed a potential health, safety or personal rights risk to persons in care.

During record review, LPA observed that R1 file missing LIC602 form signed by thier doctor as required by this regulation which poses/posed a potential health, safety or personal rights risk to persons in care.

87211 Reporting Requirements (a) Each licensee shall furnish (...) (1) A written report (...) to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. (...) (D) Any incident which threatens the welfare, safety or health of any resident, such as (...) unexplained absence of any resident. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not report R1's unsupervised absence from the facility, which poses a potential health, safety, and personal rights risk to residents in care.

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure that resident (R1) was properly supervised during outing, which poses an immediate health, safety, and personal rights risk to residents in care.

Based on observation and record review, the licensee did not comply with the section cited above in two (2) of three (3) residents records reviewed and two (2) of five (5) rooms toured which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in one (1) out of three (3) records reviewed which poses a potential health, safety or personal rights risk to persons in care.

87411-Personnel Requirements-General-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on documentation, licensee did not provide adequate care and supervision when 1 resident battered another resident. Facility is in violation of this section. This poses an immediate health and safety risk to residents in care.