Bethesda Gardens Monument

A complaint revisit was completed on 1/22/25 for all previous deficiencies cited on 10/17/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure resident' s medication administration record (MAR) contained accurate information, affecting four of seven sample residents (#24, #26, #31 and #32). (Cross-reference S1568)This deficiency was cited previously during a state licensure complaint revisit 10/17/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Residence PolicyThe residence' s Medication Administration policy, dated December 2024, read in part: "Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications."2. Resident #31 was admitted to the residence on 3/17/21 with diagnosis including frontotemporal dementia. a. SeroquelA written practitioner' s order, dated 4/11/24, directed the residence to administer Seroquel 25 mg every morning. However, the December 2024 MAR revealed a blank space at the time of administration on 12/18/24.b. TrazodoneA written practitioner' s order, dated 9/3/24, directed the residence to administer trazodone 50 mg every morning. However, the December 2024 M.. Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, except for those medications which a resident self-administers, affecting six of seven sample residents (#24, #26, #31, #32, #34 and #35). (Cross-reference S1600)This deficiency was cited previously during a state licensure complaint revisit on 10/17/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Residence PolicyThe residence' s medication system policy, dated December 2024, read in part: "The residence licensed nurse is responsible for ensuring oversight and supervision for following physician orders."2. Record ReviewResident #26 was admitted to the residence on 2/16//24 with diagnoses including dementia.a. Sertraline A written practitioner' s order, dated 10/22/24, directed the residence to administer sertraline 25 mg every morning. However, the November 2024 MAR revealed the residence failed to administer the medication on 11/1/24 through 11/30/24 due to the residence not having the medication in stock, for a total of 30 missed doses.b. Aspercreme PatchA written practitioner' s order, dated 5/7/24, directed the residence to administer ..

A licensure complaint, prompted by #CO38884, was completed on 1/22/25. Deficiencies were cited. Based on interview and record review, the residence failed to ensure resident' s medication administration record (MAR) contained accurate information, affecting four of seven sample residents (#24, #26, #31 and #32). (Cross-reference S1568)Findings include:1. Residence PolicyThe residence' s Medication Administration policy, dated December 2024, read in part: "Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications."2. Resident #31 was admitted to the residence on 3/17/21 with diagnosis including frontotemporal dementia. a. SeroquelA written practitioner' s order, dated 4/11/24, directed the residence to administer Seroquel 25 mg every morning. However, the December 2024 MAR revealed a blank space at the time of administration on 12/18/24.b. TrazodoneA written practitioner' s order, dated 9/3/24, directed the residence to administer trazodone 50 mg every morning. However, the December 2024 MAR revealed a blank space at the time of administration on 12/18/24 and 12/26/24.c. LoperamideA written practitioner' s order, dated 6/17/24, directed the residence to administer loperamide 2 mg daily. However, the December 2024 MAR revealed a blank spac.. Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, except for those medications which a resident self-administers, affecting six of seven sample residents (#24, #26, #31, #32, #34 and #35). (Cross-reference S1600)Findings include:1. Residence PolicyThe residence' s medication system policy, dated December 2024, read in part: "The residence licensed nurse is responsible for ensuring oversight and supervision for following physician orders."2. Record ReviewResident #26 was admitted to the residence on 2/16//24 with diagnoses including dementia.a. Sertraline A written practitioner' s order, dated 10/22/24, directed the residence to administer sertraline 25 mg every morning. However, the November 2024 MAR revealed the residence failed to administer the medication on 11/1/24 through 11/30/24 due to the residence not having the medication in stock, for a total of 30 missed doses.b. Aspercreme PatchA written practitioner' s order, dated 5/7/24, directed the residence to administer Aspercreme external patch 4% daily. However, the November 2024 MAR revealed the residence failed to administer the patch on 11/1-11/20/24, due to the residence not having the medication in stock, for a total of 20 missed patche..

A complaint revisit was completed on 1/22/25 for the previous deficiency cited on 10/17/24. A deficiency was cited. Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, except for those medications which a resident self-administers, affecting six of seven sample residents (#24, #26, #31, #32, #34 and #35). (Cross-reference S1600)This deficiency was cited previously during a state licensure complaint revisit on 10/17/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Residence PolicyThe residence' s medication system policy, dated December 2024, read in part: "The residence licensed nurse is responsible for ensuring oversight and supervision for following physician orders."2. Record ReviewResident #26 was admitted to the residence on 2/16//24 with diagnoses including dementia.a. Sertraline A written practitioner' s order, dated 10/22/24, directed the residence to administer sertraline 25 mg every morning. However, the November 2024 MAR revealed the residence failed to administer the medication on 11/1/24 through 11/30/24 due to the residence not having the medication in stock, for a total of 30 missed doses.b. Aspercreme PatchA written practitioner' s order, dated 5/7/24, directed the residence to administer Aspercreme external patch 4% daily. However, the November 2024 MAR revealed the residence failed to administer the patch on 11/1-11/20/24, due to the residence not having the medication in stock, for a total of 20 missed patches.c. TramadolA written practitioner' s order, dated 2/19/24, directed the residence to administer tramadol 150 mg twice daily. However, the December 2024 MAR revealed the residence failed to administer the medication on 12/18-12/30/24, due to the residence not having the medication in stock, for a total of 26 missed doses.3. InterviewsOn 1/22/25 at 11:18 a.m., Staff #17 said that when the residence did not have medications in stock, she n..

A relicensure and complaint revisit was completed on 1/22/25 for the previous deficiency cited on 10/17/24. A deficiency was cited. Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, except for those medications which a resident self-administers, affecting six of seven sample residents (#24, #26, #31, #32, #34 and #35). (Cross-reference S1600)This deficiency was cited previously during a state licensure complaint revisit on 10/17/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Residence PolicyThe residence' s medication system policy, dated December 2024, read in part: "The residence licensed nurse is responsible for ensuring oversight and supervision for following physician orders."2. Record ReviewResident #26 was admitted to the residence on 2/16//24 with diagnoses including dementia.a. Sertraline A written practitioner' s order, dated 10/22/24, directed the residence to administer sertraline 25 mg every morning. However, the November 2024 MAR revealed the residence failed to administer the medication on 11/1/24 through 11/30/24 due to the residence not having the medication in stock, for a total of 30 missed doses.b. Aspercreme PatchA written practitioner' s order, dated 5/7/24, directed the residence to administer Aspercreme external patch 4% daily. However, the November 2024 MAR revealed the residence failed to administer the patch on 11/1-11/20/24, due to the residence not having the medication in stock, for a total of 20 missed patches.c. TramadolA written practitioner' s order, dated 2/19/24, directed the residence to administer tramadol 150 mg twice daily. However, the December 2024 MAR revealed the residence failed to administer the medication on 12/18-12/30/24, due to the residence not having the medication in stock, for a total of 26 missed doses.3. InterviewsOn 1/22/25 at 11:18 a.m., Staff #17 said that when the residence did not have medications in stock, she n..