Inspection Reports for
Bethany Home Association of Lindsborg, Kansas
321 N CHESTNUT, LINDSBORG, KS, 67456
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
12.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
103% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
40
30
20
10
0
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 18, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
All deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 19, 2016
Visit Reason
The visit was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be an "E" level deficiency, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective January 18, 2017.
Deficiencies (1)
The facility had an "E" level deficiency pattern that constituted no actual harm but had potential for more than minimal harm that was not immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 5
Date: Dec 19, 2016
Visit Reason
Health Resurvey and Complaint investigation #108540 and #108749 conducted to assess compliance with care standards and investigate complaints.
Complaint Details
The visit was triggered by complaints related to pressure ulcer care, accident hazards and supervision, medication management, and infection control practices.
Findings
The facility was found deficient in multiple areas including failure to prevent and treat pressure ulcers, inadequate supervision leading to accidents, failure to manage unnecessary medications, failure to conduct proper drug regimen reviews, and inadequate infection control practices.
Deficiencies (5)
F314: The facility failed to provide care and services to prevent the development and worsening of pressure ulcers for Resident #5, including failure to promote healing and prevent additional ulcers.
F323: The facility failed to ensure a safe environment and adequate supervision, resulting in Resident #5 sustaining a skin tear requiring sutures and Resident #92 experiencing multiple falls due to unsafe use of an electric recliner.
F329: The facility failed to ensure Residents #85 and #82 did not receive unnecessary medications, including failure to follow up on pharmacist recommendations for gradual dose reduction and failure to evaluate duplicate use of antidepressants.
F428: The facility's pharmacist failed to identify and address irregularities in drug regimens, including failure to address multiple antidepressant medications for Resident #82.
F441: The facility failed to follow proper infection control practices while cleaning a resident's room, including improper glove use and cleaning methods, placing residents at risk for infection.
Report Facts
Resident census: 92
Sample size: 15
Skin tear sutures: 16
Medication dose: 12.5
Medication dose: 100
Medication dose: 0.5
Medication dose: 50
Fall risk score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse G | Provided information on Resident #82's behaviors and medication management | |
| Medication Aide K | Involved in incident where Resident #5 sustained skin tear due to lack of supervision | |
| Nurse Aide L | Assisted Resident #5 during toileting incident leading to skin tear | |
| Administrative Nurse D | Reported physician non-response to pharmacist recommendations and commented on infection control deficiencies | |
| Housekeeping Staff A | Observed performing improper cleaning procedures in resident's bathroom | |
| Housekeeping Supervisor B | Provided guidance on proper cleaning procedures |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Dec 19, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey conducted on December 19, 2016.
Findings
The facility identified multiple deficiencies related to pressure ulcer care, electric recliner safety, fall interventions, pharmacy reviews of psychoactive medications, and housekeeping sanitation practices. Corrective actions include updating care plans, staff re-education, policy revisions, and ongoing monitoring through quality assurance and risk management meetings.
Deficiencies (5)
F314: The care plan was updated to include current pressure ulcer treatments and interventions to promote healing and prevent additional pressure ulcers. Nursing staff will be re-educated and performance monitored through weekly meetings.
F323: The identified electric recliner power box was removed and the electric remote disabled. Policies and evaluation checklists were amended, and staff will be educated on safe use and monitoring.
F329: Pharmacy reviews of psychoactive medications were completed with no changes ordered. Monthly reviews will continue with nursing staff monitoring compliance and physician communication protocols established.
F428: Pharmacy review of psychoactive medications was completed with no changes ordered. Monthly reviews and compliance monitoring will continue, with procedures for physician refusal to follow guidelines.
F441: Housekeeping staff received verbal instruction on glove use and cleaning procedures. Additional formal training will be held, and compliance monitored through quarterly inspections and competency checks.
Report Facts
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kriston Erickson | CEO | Submitted the Plan of Correction |
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 19, 2016
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and enforcement remedies were recommended due to failure to achieve substantial compliance.
Deficiencies (1)
The facility was cited with deficiencies at an 'F' level under the Life Safety Code survey, indicating no harm but potential for more than minimal harm without immediate jeopardy.
Report Facts
Effective date for denial of payments: Jan 19, 2017
Effective date for provider agreement termination: Apr 19, 2017
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the survey report and involved in enforcement actions. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 18, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the previously reported deficiency related to regulation 483.25(h) was corrected as of 08/18/2016. No uncorrected deficiencies were noted at the time of this revisit.
Deficiencies (1)
Regulation 483.25(h) deficiency was corrected as of 08/18/2016.
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 1
Date: Aug 4, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#103338) regarding the facility's failure to provide adequate supervision to prevent accidents.
Complaint Details
This visit was triggered by Complaint Investigation #103338. The complaint was substantiated based on findings that the resident was left with a hot pack on his/her back longer than recommended, causing skin redness.
Findings
The facility failed to provide adequate supervision for one resident who received a hot pack on his/her back longer than the recommended time, resulting in a reddened area. Staff left the hot pack on for approximately 50 minutes instead of the recommended 15-30 minutes, causing skin irritation but no blistering.
Deficiencies (1)
483.25(h) The facility failed to ensure adequate supervision and monitoring of Resident #1 when a hot pack was left on the resident's back for 50 minutes, causing a reddened area and risk of injury.
Report Facts
Resident census: 91
Duration of hot pack application: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Therapy Staff B | Therapy Staff | Placed the hot pack on the resident's back and left it on too long. |
| Therapy Manager C | Therapy Manager | Confirmed the hot pack was left on too long and staff should have checked the resident's skin. |
| Nurse A | Nurse | Assessed the resident's back and noted the reddened area. |
| Nurse D | Nurse | Reported the resident's back was red and confirmed the hot pack duration. |
| Nurse Aide E | Nurse Aide | Removed the hot pack but did not check the resident's skin. |
| Administrative Nurse F | Administrative Nurse | Verified the hot pack was left on for 50 minutes, causing redness. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 4, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'D' level deficiency indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Aug 4, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey at Bethany Home.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint investigation at Bethany Home dated 08/04/2016.
Findings
The facility developed and implemented a facility-wide system to assure correction and continued compliance. Education and disciplinary review were conducted regarding the proper use of commercial hot packs and thermal agents, with reeducation of contracted therapy staff and restorative aides.
Deficiencies (2)
F0000: The facility has developed and will implement a system to assure correction and continued compliance with regulations. The Statement of Deficiencies will be reviewed by the Quality Assurance & Process Improvement Committee.
F323-D: Education and disciplinary review were conducted by the Director of Nursing and therapy manager regarding the use of commercial hot packs. Staff were reeducated, completed competency checklists, and demonstrated proper procedures. Certified nursing assistants were notified not to apply or remove hot packs.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kriston Erickson | CEO | Submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Oct 30, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected by the revisit date of 10/30/2015.
Deficiencies (4)
Regulation 483.20(g)-(j) deficiency was corrected by 10/30/2015.
Regulation 483.20(d), 483.20(k)(1) deficiency was corrected by 10/30/2015.
Regulation 483.20(d)(3), 483.10(k)(2) deficiency was corrected by 10/30/2015.
Regulation 483.65 deficiency was corrected by 10/30/2015.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Oct 9, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey.
Findings
The facility identified deficiencies related to resident assessments, care plan updates, coordination with Hospice services, and infection control practices. Corrective actions include reassessments, staff education, audits, and ongoing monitoring to ensure compliance.
Deficiencies (5)
F0000 The facility has developed and will implement a system to assure correction and continued compliance with regulations. The Statement of Deficiencies will be reviewed by the Quality Assurance/Assessment Committee.
F278-D Residents will receive new assessments to evaluate documentation and care plans, with updates made as needed. Staff will be educated on reporting changes and ongoing monitoring will be conducted through Risk Management meetings.
F279-D Care plans for residents with indwelling catheters will be updated and audited. Staff will be reeducated on timely care plan updates and multidisciplinary review will ensure continued compliance.
F280-D Care plans will be updated to include coordination with Hospice agencies. Nursing staff will review Hospice records and receive education on timely care plan updates.
F441-D Nursing staff will assess residents for adverse outcomes related to infection control and wound care. Licensed nurses will complete training and demonstrate competency. Ongoing observation and education will be conducted to prevent recurrence.
Report Facts
Corrective action completion date: Oct 30, 2015
Inspection Report
Re-Inspection
Census: 94
Deficiencies: 4
Date: Oct 1, 2015
Visit Reason
The inspection was a Health Resurvey and Complaint Investigations #90777 and #91271 to assess compliance with regulatory requirements.
Complaint Details
The inspection included complaint investigations #90777 and #91271.
Findings
The facility failed to provide accurate assessments reflecting residents' status, develop and revise comprehensive care plans, and maintain infection control measures. Specific deficiencies involved inaccurate assessments for two residents, incomplete care plans for urinary catheter care and hospice coordination, and improper wound care infection control practices.
Deficiencies (4)
F278: The facility failed to provide an assessment accurately reflecting the status of two residents, including restorative services and wandering risk.
F279: The facility failed to develop a comprehensive care plan directing staff on care of an indwelling urinary catheter for one resident.
F280: The facility failed to review and revise the hospice care plan to include coordination of care between hospice and facility staff for one resident.
F441: The facility failed to maintain infection control measures during wound care for one resident, including handling clean supplies with soiled gloves.
Report Facts
Resident census: 94
Sample size: 15
Residents reviewed for specific issues: 1
Residents reviewed for hospice care: 1
Inspection Report
Enforcement
Deficiencies: 1
Date: Oct 1, 2015
Visit Reason
The visit was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found isolated 'D' level deficiencies that constituted no actual harm but had potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective October 30, 2015.
Deficiencies (1)
The facility had isolated 'D' level deficiencies that constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement decision letter. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 21, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm, and not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Deficiencies (1)
The facility was cited for 'F' level deficiencies that were widespread with no harm but potential for more than minimal harm, not constituting immediate jeopardy.
Report Facts
Effective date for denial of payments: Oct 21, 2015
Provider agreement termination date: Jan 21, 2016
Plan of Correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Dec 3, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the deficiencies related to regulations 483.13(c) and 483.25(h) were corrected as of 12/03/2014.
Deficiencies (2)
Regulation 483.13(c): Previously cited deficiency was corrected by the revisit date.
Regulation 483.25(h): Previously cited deficiency was corrected by the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Dec 3, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Bethany Home.
Complaint Details
This Plan of Correction relates to a complaint investigation with allegations of abuse, neglect, and exploitation. The investigation was completed and findings were addressed in the plan.
Findings
The plan addresses allegations of abuse, neglect, and exploitation, and issues related to resident lifting and transfers. The facility outlines corrective actions including investigations, staff education, and monitoring to ensure compliance.
Deficiencies (3)
F0000: The facility submitted a Plan of Correction as a credible allegation of substantial compliance for deficiencies cited during the survey. The plan will be reviewed by the Quality Assurance/Assessment Committee.
F226-D: The completed investigation for the complaint was provided to the state surveyor. All allegations of abuse, neglect, and exploitation will be reported and monitored through Risk Management and QAA meetings. Staff will receive education on these topics upon hire and bi-annually.
F323-D: Residents were changed to total sling lifts for transfers and staff were reeducated. All nursing staff must complete training on resident lifting and transfers by December 3, 2014. Electronic reporting procedures for resident condition changes were implemented and will be monitored.
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 3
Date: Nov 3, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#80325) regarding allegations of abuse and failure to report, as well as concerns about accident hazards and supervision related to resident transfers.
Complaint Details
The complaint investigation (#80325) was substantiated in part, finding failure to report alleged abuse and failure to prevent injury due to inadequate supervision and transfer techniques.
Findings
The facility failed to report an allegation of potential abuse by staff to the state agency and failed to identify declines in residents' ability to safely use sit to stand lifts, resulting in bruising and pain for two residents. Staff training on lift use was inadequate beyond initial hire training.
Deficiencies (3)
F 226: The facility failed to report Resident #3's allegation of potential abuse by staff to the appropriate state agency despite an internal investigation and suspension of the alleged perpetrator.
F 323: The facility failed to identify Resident #1's decline in ability to safely transfer with a sit to stand lift, resulting in significant bruising and pain due to improper use of the lift.
F 323: The facility failed to identify Resident #2's inability to safely transfer with the sit to stand lift, resulting in a facial bruise.
Report Facts
Resident census: 87
Sample size: 4
White blood cell count: 14.2
Red blood cell count: 3.27
Bruise measurement: 14
Bruise measurement: 7
Bruise measurement: 4
Bruise measurement: 8
Bruise measurement: 4
Bruise measurement: 7
Bruise measurement: 1.4
Bruise measurement: 1.8
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 14, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected by 07/31/2014 as verified during this revisit.
Report Facts
Deficiencies corrected: 15
Inspection Report
Plan of Correction
Deficiencies: 15
Date: Jul 10, 2014
Visit Reason
This document is a Plan of Correction submitted by Bethany Home Association in response to deficiencies cited during a prior survey. It outlines corrective actions to address various regulatory compliance issues identified in the facility.
Findings
The plan details corrective actions taken or planned for multiple deficiencies including medication refusal protocols, mail delivery, incident reporting, resident preferences, depression screening and care planning, maintenance and housekeeping procedures, elopement risk interventions, food safety, and medication management.
Deficiencies (15)
F0000: Facility developed a system to assure correction and continued compliance with cited deficiencies and provided the deficiency list to the Quality Assurance and Assessment committee.
F157-D: Medication refusal protocol implemented including alerts for refusals over 3 days and staff inservice; resident #100's medication regimen updated and compliant.
F170-E: Mail delivery to all residents ensured Monday through Saturday with monitoring by resident council.
F225-D: Incident reporting policy updated to include unwitnessed events with injury for residents with impaired cognition; staff inservice planned.
F242-D: Resident preferences checklist developed and incorporated into care plans for residents with impaired cognition and decision making.
F250-D: Depression screening using GDS implemented for at-risk residents; care plans updated with intervention guidelines and suicidal ideation policy developed.
F253-D: Maintenance and housekeeping QA checklists updated; staff inserviced on procedures; ongoing monitoring planned.
F279-D: Care plans updated for elopement risk and medication changes; elopement prevention measures and staff training implemented.
F280-D: Invitations to care plan meetings sent to family or responsible parties with logs maintained and quarterly review by QAA committee.
F319-G: Medication refusal protocols and suicide ideation policy implemented; staff inserviced; auto alerts and quarterly monitoring established.
F323-E: Elopement risk interventions including removal of bed rails and locked chemical storage; weekly RM committee reviews and staff education.
F329-D: Medication refusal protocols reinforced with alerts and staff inservice; resident #100 medication regimen updated and compliant.
F368-E: HS snack policy developed and staff educated; resident council monitors snack offerings and preferences.
F371-E: Food safety and sanitation checklist updated; equipment cleanliness, labeling, and temperature logs monitored; staff educated on protocols.
F428-D: Medication management improved with e-MAR updates allowing better tracking of refusals; automatic notifications and quarterly reports implemented.
Report Facts
Complete Date: Jul 10, 2014
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 13
Date: Jul 2, 2014
Visit Reason
Health Resurvey and Complaint Investigations #74968, #75410 and #75311 were conducted to assess compliance with regulatory requirements.
Complaint Details
The inspection was triggered by complaint investigations #74968, #75410, and #75311. The facility was substantiated for multiple deficiencies including failure to notify physician of condition changes, failure to provide privacy, failure to report injuries, failure to provide choices, failure to provide social services, inadequate housekeeping, failure to develop care plans, failure to involve responsible parties, failure to provide psychosocial support, inadequate supervision, failure to offer snacks, unsanitary food handling, and failure to monitor medication regimen.
Findings
The facility was found deficient in multiple areas including failure to notify physician of resident condition changes, failure to provide privacy in mail handling, failure to report injuries of unknown origin, failure to provide resident choices, failure to provide medically-related social services, inadequate housekeeping and maintenance, failure to develop comprehensive care plans, failure to involve responsible parties in care planning, failure to provide psychosocial support, inadequate supervision to prevent accidents, failure to offer evening snacks, unsanitary food handling, and failure to monitor medication regimen and report irregularities.
Deficiencies (13)
F 157: Facility failed to notify physician and responsible party of changes in mood, behavior, and medication refusal for Resident #100.
F 170: Facility failed to provide residents the right to privacy in written communications, including sending and promptly receiving unopened mail.
F 225: Facility failed to report injuries from unknown origin to the State agency for Resident #59.
F 242: Facility failed to provide choices for bathing, time to rise, and time to retire to bed for Resident #85.
F 250: Facility failed to provide medically-related social services to maintain highest mental and psychosocial well-being for Resident #100.
F 253: Facility failed to maintain sanitary, orderly, and comfortable interior on one resident hall with multiple maintenance and housekeeping deficiencies.
F 279: Facility failed to develop comprehensive care plans for Residents #100 and #69, including lack of care plan for mood disorder and elopement supervision.
F 280: Facility failed to invite Resident #85's responsible party to care plan meetings.
F 319: Facility failed to provide care and services to maintain highest mental and psychosocial functioning for Resident #100 with mood disorder and suicidal ideation.
F 323: Facility failed to adequately supervise Resident #69 at elopement risk and failed to assess side rails for unsafe gaps for Resident #59; also failed to secure hazardous chemicals.
F 368: Facility failed to offer evening snacks to Residents #10 and #70 who desired them.
F 371: Facility failed to store, prepare, distribute, and serve food under sanitary conditions, including failure to monitor food temperatures, label foods, prevent contamination, and maintain clean equipment.
F 428: Facility's pharmacy consultant failed to identify and report medication irregularities related to Resident #100's refusal of prescribed mood disorder medication.
Report Facts
Deficiencies cited: 13
Resident census: 90
Sampled residents: 18
Medication refusal period: 85
Side rail gap measurements: Array
Temperature log blanks: 12
Temperature log blanks: 14
Temperature log blanks: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse L | Nurse | Verified Resident #100 was depressed and refused to come out of room. |
| Nurse D | Administrative Nurse | Verified Resident #100's increased behaviors and mood, lack of awareness of medication refusal, and need for psychiatric evaluation. |
| Nurse E | Physician's Office Nurse | Verified facility should have notified physician regarding Resident #100's mood changes and medication refusal. |
| Nurse J | Nurse | Verified Resident #69's exit seeking behaviors and lack of supervision. |
| Nurse Aide H | Nurse Aide | Verified Resident #100's suicidal comments and medication refusal. |
| Nurse Aide I | Nurse Aide | Verified Resident #100's statements about being better off dead. |
| Housekeeping Staff N | Housekeeping Staff | Verified housekeeping cart should be locked when unattended. |
| Nurse M | Licensed Nursing Staff | Explained responsibility for inviting family to care plan meetings. |
| Social Service Staff C | Social Service Staff | Stated responsible party did not attend care plan meetings. |
| Nurse W | Nurse | Stated not all residents receive evening snacks. |
| Dietary Staff T | Dietary Staff | Observed contaminating food during meal service. |
| Dietary Staff U | Dietary Staff | Observed contaminating food during meal service. |
Inspection Report
Enforcement
Deficiencies: 0
Date: Jul 2, 2014
Visit Reason
The inspection was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency at a 'G' level. As a result, enforcement remedies including denial of payment for new Medicare admissions effective October 2, 2014, were imposed due to failure to achieve substantial compliance.
Report Facts
Enforcement effective date: Oct 2, 2014
Enforcement review period: 6
Termination recommendation date: Jan 2, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Peters | Administrator | Facility administrator named in report header |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions regarding the enforcement letter |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 30, 2014
Visit Reason
The visit was a resurvey of the Assisted Living/Residential Healthcare facility to verify compliance following a prior inspection.
Findings
The resurvey resulted in a finding of no deficiency citations at the facility.
Inspection Report
Life Safety
Deficiencies: 1
Date: May 15, 2014
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited with an 'F' level deficiency that was widespread, indicating noncompliance with Life Safety Code requirements with potential for more than minimal harm but no immediate jeopardy.
Inspection Report
Deficiencies: 0
Date: Jul 15, 2013
Visit Reason
The health survey was conducted to assess compliance with applicable regulations under 42 CFR, Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in a finding of no deficiency citations with respect to the applicable regulations.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jun 15, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected.
Findings
The report confirms that deficiencies identified in the prior survey were corrected by the revisit date of 06/15/2012.
Deficiencies (2)
Regulation 483.35(i) deficiency was corrected as of 06/15/2012.
Regulation 483.60(a),(b) deficiency was corrected as of 06/15/2012.
Report Facts
Correction completion date: Jun 15, 2012
Followup to Survey Completed on: May 17, 2012
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 25, 2012
Visit Reason
This document is a plan of correction submitted in response to deficiencies identified in a prior inspection of Bethany Home Association.
Findings
No specific findings or deficiencies are detailed in this document; it serves as a corrective action plan linked to a prior deficiency report.
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 2
Date: May 17, 2012
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation #55113 at the facility.
Complaint Details
The visit was triggered by complaint investigation #55113. The findings included failure to maintain sanitary food handling and failure to monitor medication expiration dates.
Findings
The facility failed to maintain sanitary food preparation and beverage service conditions and failed to monitor expiration dates of stock medications and resident medications, potentially placing residents at risk.
Deficiencies (2)
F 371: The facility failed to prepare and serve beverages and food under sanitary conditions, including incomplete hairnet coverage by dietary staff and improper handling of residents' glasses and coffee cups.
F 425: The facility failed to monitor expiration dates of stock medications on medication carts and for one resident, potentially allowing administration of outdated medications.
Report Facts
Resident census: 93
Sample residents: 17
Dietary staff observed: 5
Dietary staff observed: 3
Medication carts: 6
Medication carts with expired meds: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide E | Verified expired medications on medication carts during observation. | |
| Nurse D | Verified staff were to monitor stock medications for outdated medications and dispose of them. | |
| Nurse B | Stated the facility had no written policy for monitoring outdated medications and described the unwritten policy. | |
| Dietary Staff A | Verified hairnet and beverage handling policies during observation. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N059001 POC ZP2Q11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for Bethany Home Association ALF 063014.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a record of the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N059001 POC RBHR11
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory event for the facility identified as State ID N059001.
Findings
No deficiency details or findings are provided in this document. It only references the Plan of Correction status and contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N059001 POC V1IO11
Visit Reason
This document is a plan of correction submitted by Bethany Home to address deficiencies cited in a prior inspection related to food sanitation and medication management.
Findings
The plan of correction addresses sanitary practices in food preparation, including updated policies and use of hair restraints, and revises the procedure for checking out-dated resident medications monthly.
Deficiencies (2)
F371-E: Food preparation and employee sanitary practices were reviewed and updated. New bouffant hair restraints were implemented and monitored daily for dietary staff compliance.
F425-D: The practice for checking out-dated resident medications was revised to require monthly checks by the night charge nurse with oversight by unit managers.
Report Facts
Complete Date: Jun 15, 2012
Complete Date: Jun 7, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emery Myers | Director of Nursing | Submitted the plan of correction and involved in education of nursing staff on medication checks |
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