BETHESDA SENIOR CARE

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 07/24/2024 Plan of Correction Administratoe shall submit letter of understanding of this Regulation and will conduct staff training regarding medication management and send proof to Department. All POC documents are due by 07/24/24.

Official classification

Type B

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 08/05/2024 Plan of Correction Licensee agrees to have the fire extinguisher serviced and will send a receipt and/or photograph of the fire extinguisher having been serviced. The receipt/photograph will be due by the POC due date - 08/05/24.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 08/05/2024 Plan of Correction Licensee shall ensure that staff, S1 and all other staff members have Active CPR/FIRST AID certification as required and send proof to Department by POC due date -08/05/24.

Official classification

Type A

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee shall send a written statement to CCL of understanding of regulation for 87211 for reporting requirements and shall do training with staff. POC documents should be sent to CCL by POC date-11/09/23.

Deadline recorded: Nov 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator agreed to submit a self-certification of understanding the regulation ,87405 (d)(2) and will make sure to report any reportable incidents to CCL as required and submit proof to CCL by POC date-11/09/23.

Deadline recorded: Nov 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 09/15/2023 Plan of Correction Licensee will make sure that ,LIC501-Personal record form for S2, LIC508(Criminal record statement ) for S1 and S2 ,LIC9052 (Employee Rights) for S1 and S2 will be completed in staff's files by POC date-09/15/23 and will submit proof to CCL.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 09/15/2023 Plan of Correction Licensee will complete LIC503-Health Screening for S2 in staff's file and by POC date-09/15/23 and will submit proof to CCL.

Official classification

Type B

Official code

87411(d)

Regulation authority

CCR

What the official deficiency says

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 09/15/2023 Plan of Correction Licensee will complete required training documentation for S1 and S2 and will send proof to CCL by POC date--09/15/23.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 09/15/2023 Plan of Correction Licensee will complete LIC602 for R1 as required by this regulation and send proof to CCL by POC date-09/15/23.

Official classification

Type B

Official code

87468(b)(1)(A)

Regulation authority

CCR

What the official deficiency says

(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 09/15/2023 Plan of Correction Licensee will complete LIC613 (Personal Rights) and Consent forms as required per regulation for R1 and R2 files and send proof to CCL by POC date-09/15/23.

Official classification

Type A

Official code

87705(c)(4)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator will complete a statement of understanding regarding regulation 87705 and submit statement to Department by POC due date of 7/20/2022.

Deadline recorded: Jul 20, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator will complete a statement of understanding regarding regulation 87211 and submit statement to Department by POC due date of 8/3/2022.

Deadline recorded: Aug 3, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.655(a)

Regulation authority

HSC

What the official deficiency says

1569.655 Increase in fee rates; 60 days’ written notice (a) If a licensee... increases the rates of fees... the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a description of the additional costs. This requirement is not met as evidenced by: Based on interviews and record review CCL was able to determine licensee increased resident rate without notifying R1 or his representatives 60 days in advance, which poses a potential health risk to residents in care.

Official plan of correction

Administrator to review health and safety code 1569.655 Increase in fee rates for elderly residents; 60 days’ written notice stating amount of and reasons for increase. Administrator to send in a statement of understanding of rate increases. Statement to be sent into CCL by 04/05/22.

Deadline recorded: Apr 5, 2022. A deadline is not proof that correction was completed.