Bethesda Health Care Facility

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of diabetes and anxiety diagnoses for 1 of 24 residents reviewed for MDS accuracy (Resident #5).Findings include:Resident #5 was admitted to the facility on [DATE] and most recently readmitted on [DATE]. Her medical history was significant for type 2 diabetes mellitus and generalized anxiety disorder.Resident #5's care plan created 1/10/25 indicated Resident #5 had a diagnosis of diabetes. Anxiety was not included as a care focus area in Resident #5's care plan.A physician encounter note dated 10/28/25 indicated Resident #5 had a diagnosis of diet-controlled diabetes mellitus.Resident #5's physician order dated 11/19/25 indicated to administer 0.5 milligram Ativan (antianxiety medication) once a day in the evening for anxiety and unspecified mood disorder. Resident #5's annual MDS dated [DATE] coded Resident # 5 as cognitively severely impaired and as taking an antianxiety medication. The MDS did not indicate that Resident #5 had a diagnosis of diabetes or anxiety.During an interview with the MDS Nurse on 2/11/26 at 3:04 PM, she reported that Resident #5 had documented diagnoses of diabetes and generalized anxiety disorder, which should have been coded on the annual MDS. The MDS Nurse verbalized that she had missed coding the MDS to indicate that Resident #5 had diabetes and anxiety diagnoses when she completed the annual MDS on 12/23/25 and that the omission was an oversight.During an interview on 2/12/26 at 10:22 AM, the facility Administrator stated that the MDS should include all of a resident's diagnoses, and that diabetes and anxiety should have been coded on Resident #5's annual MDS to accurately reflect her current condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident with serious mental health diagnoses for 1 of 1 resident reviewed for PASRR (Resident #4). Findings included:Resident #4 was admitted to the facility on [DATE] with diagnoses which included hypertension, hyperkalemia and hyperlipidemia. The PASRR history report dated 11/01/2021, provided by the facility, revealed Resident #4 had one Level I PASRR review, completed on 11/01/2021 and the review did not meet level II criteria. The PASRR review revealed Resident #4 was noted to have no mental health diagnosis at the time of the review.A review of the active diagnosis list revealed Resident #4 had a diagnosis of generalized anxiety disorder and depressive disorder both noted as active on 03/26/2025. Review of the Psychiatrist note dated 01/20/2026 indicated Resident#4 had a chief complaint/ nature of presenting problem as mood disorder with psychosis/bipolar. The note documented medication prescribed for mood disorder with psychosis /bipolar was Zyprexa 5 milligrams one tablet by mouth (po) every bedtime.Review of Resident #4's electronic and paper medical record revealed no evidence a request was submitted for an evaluation for level II PASRR determination. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. The MDS indicated the resident had a diagnosis of bipolar disorder.During an interview on 02/11/2026 at 11:01 AM, MDS Coordinator stated that her usual practice was to notify the Business Office Manager (BOM) of the resident's new mental illness diagnoses and the BOM was responsible for sending the request to the state agency for evaluation for the level II PASRR. The MDS Coordinator stated that when the provider added the new mental illness diagnoses for Resident#4 in March 2025 she failed to notify the BOM so she could submit request for level II PASRR evaluation. During an interview on 02/12/2026 at 8:44 AM, the Business Office Manager (BOM) confirmed she was responsible for requesting level II PASRR evaluations for residents at the facility. She stated the MDS Coordinator did not notify her of the new mental health diagnoses of anxiety disorder, and depressive disorder for Resident #4 in March 2025. The BOM also stated she was not made aware of the bipolar disorder diagnosis in January 2026. She further stated that she would continue to communicate with the MDS Coordinator about the new mental health diagnoses and request level II PASRR evaluations. An interview was conducted with the Administrator on 02/12/26 at 8:57 AM who revealed the facility received Resident #4's level I PASRR information after his admission to the facility on [DATE] indicating she did not have any mental illness. She added the MDS Coordinator was responsible for notifying the BOM of Resident #4's new mental health diagnoses in March 2025 and the BOM would have requested a level II PASRR evaluation. She added Resident #4's level II PASRR evaluation should have been completed in March 2025 when the new mental illness diagnoses were added in the medical records.

Based on observations and staff interviews, the facility failed to discard expired food items and food items with signs of spoilage and failed to label and date resident's personal food items stored in 2 of 2 nourishment room refrigerators (Main Unit and Locked Unit). This practice had the potential to cause foodborne illnesses.Findings included:a. Observation of the Main Unit nourishment room refrigerator with the facility's Dietary Manager (DM) on 2/11/26 at 2:05 PM revealed the following: - A jar of strawberry preserves that was approximately a third full with a use by date of 1/19/26; - An unopened 8 ounces bottle of high protein milkshake with a best if used by date of 1/30/26; - Three unopened bottles of nutritional energy drink with a use by date of 10/9/25; - A 2-liter soft drink bottle that was half full of an orange liquid that was not labeled or dated; - A 500-milliliter disposable water bottle with a purplish liquid that was not labeled or dated; - A 500-milliliter soft drink bottle that was approximately half full of a brownish liquid that was not labeled or dated. The Unit Manager who came into the nourishment room during the observation placed the above food items in the trash can. The Unit Manager stated that nursing staff were supposed to ensure that all food items in the nourishment refrigerator were dated and labeled and that expired food items were discarded.b. Observation of the Locked Unit nourishment room refrigerator with the DM on 2/11/26 at 2:20 PM revealed the following: - A cup of yogurt with an expiration date of 1/9/26; - A pack of 3 prepackaged apples with an opened by date of 12/15/25 and best by date of 1/29/26. Two apples in the packet were observed to have grayish fuzz. The Locked Unit Charge Nurse who was present during the observation placed the items in the trash can. The Locked Unit Charge Nurse indicated that nurses were responsible for labeling the food items and checking the expiry dates and that she should have checked the refrigerator at the beginning of her shift at 7:00 am and ensured that expired food items were discarded to prevent food borne illnesses. During an interview on 2/11/26 at 2:40 PM with the Director of Nursing (DON), she stated that she expected nursing staff to inspect the nourishment room refrigerators to ensure expired food items were not left in the refrigerator and that all food items were labeled and dated.During an interview with the facility Administrator on 2/11/26 at 2:45 PM, she indicated that her expectation was to have all food items in the nourishment room refrigerators dated and labeled, have no outdated food items in the refrigerator and that any expired food items should have been thrown out by nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide the required Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) (form 10123) for 1 of 3 sampled residents reviewed for beneficiary protection notification review (Resident #49).
The findings included:
Resident #49 was admitted to the facility on [DATE] with Medicare Part A skilled services.
Resident #49's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired.
Resident #49's Medicare Part A skilled services ended on 4/08/2024 and her Medicare Part A Skilled Nursing Facility benefit was not exhausted. She remained in the facility.
Record review revealed no evidence that Resident #49 or the resident's Responsible Party (RP) was provided with the NOMNC.
During an interview with the Secretary Assistant on 11/31/2024 at 10:51AM, she stated she provided the RP with the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) on 03/25/2024 but she failed to provide NOMNC notice. The Secretary Assistant stated she was not aware she should have provided the RP with the NOMNC notice due to the resident remaining in the facility and still having Medicare Part A days remaining. The Secretary Assistant indicated moving forward she would provide the NOMNC notice to the residents or RP as required by the federal guidelines.
During an interview with the Administrator on 11/31/2024 at 11:05 AM, she stated Resident #49 remained in the facility after being discharged from rehab services and the RP should have received the NOMNC as required by the federal guidelines.