A list of the most recent deficiencies for Carriage Hill Bethesda. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Post nurse staffing information every day. | Health | 2022-08-08 | 2022-11-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-08 | 2022-09-30 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-08 | 2022-09-30 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-08 | 2022-09-30 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-08-08 | 2022-09-30 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-08 | 2022-09-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-08 | 2022-09-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-08 | 2022-09-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-08 | 2022-09-30 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-08-08 | 2022-09-30 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-08-08 | 2022-09-30 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-08-08 | 2022-09-30 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-08-08 | 2022-09-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-08 | 2022-09-30 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-08-08 | 2022-09-30 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-08-08 | 2022-09-30 | Y |
| Report COVID19 data to residents and families. | Health | 2022-08-08 | 2022-09-30 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-08-08 | 2022-09-30 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-08 | 2022-09-30 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-08 | 2022-09-30 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-14 | 2020-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-14 | 2020-03-15 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-02-14 | 2020-03-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-02-14 | 2020-03-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-02-14 | 2020-03-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-02-14 | 2020-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-14 | 2020-03-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-01-07 | 2019-01-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-07 | 2019-01-31 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-01-07 | 2019-01-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-01-07 | 2019-01-31 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-01-07 | 2019-01-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-07 | 2019-01-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-01-07 | 2019-01-31 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-01-02 | 2019-01-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-01 | 2018-03-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-02-01 | 2018-03-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-02-01 | 2018-03-15 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2018-02-01 | 2018-03-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-01 | 2018-03-15 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-02-01 | 2018-03-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-02-01 | 2018-03-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-02-05 | 2018-03-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-02-05 | 2018-03-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-02-05 | 2018-03-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-02-05 | 2018-03-15 | N |
