Inspection Reports for Bethany Home Association of Lindsborg, Kansas
321 N CHESTNUT, LINDSBORG, KS, 67456
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 18, 2017, found that all previously cited deficiencies had been corrected. Earlier inspections showed a pattern of deficiencies related primarily to resident care issues such as pressure ulcer prevention and treatment, medication management including pharmacy reviews and dose monitoring, accident prevention and supervision, and infection control practices. Several complaint investigations substantiated failures in supervision, safe use of assistive devices, abuse reporting, and sanitary food handling. Enforcement actions included a denial of payment for new Medicare admissions in 2014 due to a 'G' level deficiency, with other surveys noting deficiencies at levels up to 'F' but no immediate jeopardy or license suspensions were listed in the available reports. The facility’s record shows improvement over time, with more recent inspections confirming correction of prior deficiencies and a finding of substantial compliance.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
15.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
153% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
92 residents
Based on a December 2016 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 5
Date: Jan 18, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers 483.25(b)(1), 483.25(d)(1)(2)(n)(1)-(3), 483.45(d), 483.45(c)(1)(3)-(5), and 483.80(a)(1)(2)(4)(e)(f) were corrected as of the revisit date.
Deficiencies (5)
Deficiency related to regulation 483.25(b)(1)
Deficiency related to regulation 483.25(d)(1)(2)(n)(1)-(3)
Deficiency related to regulation 483.45(d)
Deficiency related to regulation 483.45(c)(1)(3)-(5)
Deficiency related to regulation 483.80(a)(1)(2)(4)(e)(f)
Report Facts
Deficiencies corrected: 5
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 19, 2016
Visit Reason
A Health survey was conducted to determine if the facility is 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)
"E" level deficiency, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter regarding acceptance of plan of correction and substantial compliance. |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Dec 19, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a survey conducted on December 19, 2016.
Findings
The Plan of Correction addresses multiple deficiencies including pressure ulcer care, electric recliner safety, fall interventions, pharmacy reviews of psychoactive medications, and housekeeping sanitation procedures. The facility outlines corrective actions, staff education, and monitoring plans to ensure compliance and resident safety.
Deficiencies (8)
Care plan updated for pressure ulcer treatments and interventions; updated standards and protocols for pressure sores.
Removal of electric recliner power box and updated policy and evaluation checklist for electric recliner use.
Care plan updated for fall interventions and treatments; therapy equipment reviewed and deemed appropriate.
Pharmacy review of psychoactive medications completed; ongoing monthly reviews and monitoring planned.
Pharmacy consultation documentation provided to physician with guidelines; monitoring of physician compliance.
Care Plan Team to continue interventions and add Root Cause Analysis for residents with maladaptive behavioral symptoms.
Pharmacy review of psychoactive medications for identified resident with ongoing monitoring and physician compliance measures.
Housekeeping staff provided training on glove use and cleaning procedures; additional formal training planned; monitoring through quarterly inspections.
Report Facts
Deficiencies cited: 8
Dates of pharmacy reviews: Dec 13, 2016
Dates of physician reviews: Dec 15, 2016
Plan completion date: Jan 18, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kriston Erickson | CEO | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 5
Date: Dec 19, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint investigation related to allegations including pressure ulcer care, accident hazards, medication regimen, and infection control.
Complaint Details
The visit was triggered by complaints regarding pressure ulcer care, accident hazards, medication management, and infection control.
Findings
The facility failed to provide adequate care to prevent and treat pressure ulcers for Resident #5, failed to ensure a safe environment and supervision to prevent accidents for Residents #5 and #92, failed to follow up on pharmacist recommendations for medication dose reductions for Resident #85, failed to evaluate duplicate psychotropic medications for Resident #82, and failed to maintain proper infection control practices during housekeeping.
Deficiencies (5)
Failed to provide care and services to prevent development and worsening of pressure ulcers for Resident #5.
Failed to ensure environment free from accident hazards and provide adequate supervision, resulting in skin tear requiring sutures for Resident #5 and multiple falls related to electric recliner for Resident #92.
Failed to ensure drug regimen free from unnecessary drugs by not following up on pharmacist recommendations for gradual dose reduction of Seroquel and Zoloft for Resident #85.
Failed to identify and address duplicate use of antidepressant medications for Resident #82.
Failed to maintain proper infection control practices during housekeeping, including improper glove use and cleaning methods, placing residents at risk for infection.
Report Facts
Census: 92
Sample size: 15
Pressure ulcer measurements: 3.5
Sutures: 16
BIMS score: 8
BIMS score: 7
BIMS score: 3
BIMS score: 4
Fall risk score: 13
Medication doses: 12.5
Medication doses: 100
Medication doses: 50
Medication doses: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse G | Nurse | Provided statements regarding Resident #82's behaviors and medication management |
| Medication Aide K | Medication Aide | Involved in incident where Resident #5 sustained skin tear due to lack of supervision |
| Nurse Aide L | Nurse Aide | Witnessed and reported skin tear injury to Resident #5 |
| Administrative Nurse D | Administrative Nurse | Reported physician non-response to pharmacist recommendations for Resident #85 and commented on infection control practices |
| Housekeeping Staff A | Housekeeping Staff | Observed performing improper cleaning procedures in resident's bathroom |
| Housekeeping Supervisor B | Housekeeping Supervisor | Provided statements on proper cleaning procedures |
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 19, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility to be at an "F" level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. A plan of correction was required, and enforcement remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found at "F" level with no harm but potential for more than minimal harm, not 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 report and involved in enforcement and certification. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 18, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the previously cited deficiency with ID Prefix F0323 related to regulation 483.25(h) was corrected as of 08/18/2016. No other deficiencies were noted.
Deficiencies (1)
Deficiency with ID Prefix F0323 related to regulation 483.25(h)
Report Facts
Deficiencies corrected: 1
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 4, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating 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 with 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)
Most serious deficiency found was a 'D' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as the contact person and signatory of the report letter. |
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
The complaint investigation found that the facility failed to supervise Resident #1 adequately, resulting in a hot pack being left on the resident's back longer than the recommended 15-30 minutes, causing skin redness but no blistering. The resident had intact cognition and required extensive assistance. Therapy staff and nursing aides failed to monitor the skin condition properly.
Findings
The facility failed to provide adequate supervision for one resident who received a hot pack left on longer than recommended, resulting in a reddened area on the resident's back. Staff did not monitor the resident's skin properly, placing the resident at risk for injury and burns.
Deficiencies (1)
Failure to provide 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
Census: 91
Hot pack duration: 50
Pain rating: 8
Pain rating: 7
Reddened area size: 2
Reddened area size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Therapy Staff B | Placed the hot pack on the resident's back and left it on too long | |
| Therapy Manager C | Confirmed the hot pack was left on too long and should have been monitored | |
| Nurse A | Assessed the resident's back and noted reddened area without pain | |
| Nurse D | Reported the resident's back was pretty red and hot pack was left on for 50 minutes | |
| Nurse Aide E | Removed the hot pack but did not check the resident's skin | |
| Administrative Nurse F | Verified the hot pack was left on for 50 minutes causing redness |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Oct 30, 2015
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously cited deficiencies identified by regulation numbers 483.20(g)-(j), 483.20(d), 483.20(k)(1), 483.20(d)(3), 483.10(k)(2), and 483.65 have been corrected as of the revisit date.
Deficiencies (4)
Deficiency identified under regulation 483.20(g)-(j)
Deficiency identified under regulation 483.20(d), 483.20(k)(1)
Deficiency identified under regulation 483.20(d)(3), 483.10(k)(2)
Deficiency identified under regulation 483.65
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Oct 30, 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 multiple 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 (4)
Failure to maintain accurate resident assessments and care plans.
Care plans not updated timely for residents with indwelling catheters.
Care plans not coordinated with Hospice agency documentation.
Infection control and wound care practices deficient, requiring reeducation and competency demonstration.
Report Facts
Corrective action completion date: Oct 30, 2015
Date of nurses meeting for education: Oct 7, 2015
Inspection Report
Deficiencies: 1
Date: Oct 1, 2015
Visit Reason
A Health survey was conducted to determine if the facility is 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 constitute no actual harm but have the 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)
Isolated 'D' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement decision letter. |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 4
Date: Oct 1, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #90777 and #91271 to evaluate compliance with regulatory requirements.
Complaint Details
The inspection included complaint investigations #90777 and #91271. The facility was found noncompliant in multiple areas related to resident assessments, care planning, hospice coordination, and infection control.
Findings
The facility failed to provide accurate resident assessments, develop comprehensive care plans, coordinate hospice care, and maintain infection control standards. Specific deficiencies were noted in assessment accuracy for residents #32 and #51, care planning for residents #20 and #22, hospice care coordination for resident #20, and infection control during wound care for resident #22.
Deficiencies (4)
Failed to provide an assessment accurately reflecting the status of residents #32 and #51.
Failed to develop a comprehensive care plan for resident #20 regarding indwelling urinary catheter care.
Failed to review and revise the plan of care to include hospice coordination for resident #20.
Failed to maintain infection control measures during wound care for resident #22.
Report Facts
Census: 94
Sample size: 15
Resident count for indwelling catheter review: 1
Resident count for hospice care review: 11
Resident count for wound care review: 1
Pressure ulcer size: 2.7
Pressure ulcer size: 1
Pressure ulcer size: 2.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Assisted with dressing and grooming of resident #32 and observed during wound care. | |
| Nurse B | Provided wound care for resident #22 and acknowledged infection control lapses. | |
| Nurse C | Administrative Nurse | Verified failures in assessment accuracy, care plan updates, and hospice coordination. |
| Nurse D | Nurse Aide | Provided extensive assistance with dressing/grooming for resident #32 and assisted during wound care. |
| Nurse E | Verified lack of comprehensive care plan for resident #20's urinary catheter. | |
| Nurse F | Nurse Aide | Provided assistance to resident #32 and confirmed lack of restorative program guidelines. |
| Nurse J | Verified wanderguard alarm checks for resident #51. | |
| Restorative Aide G | Reported Certified Nurse Aides provided dressing/grooming program for resident #32. | |
| Social Service Staff K | Reported on resident #51's wandering behavior and assessment inaccuracies. |
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 was in compliance 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 deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Facility found to have 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Oct 21, 2015
Provider agreement termination date: Jan 21, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Dec 3, 2014
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report shows that the previously cited deficiencies under regulations 483.13(c) and 483.25(h) were corrected as of 12/03/2014.
Deficiencies (2)
Deficiency under regulation 483.13(c)
Deficiency under regulation 483.25(h)
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Dec 3, 2014
Visit Reason
This Plan of Correction document addresses deficiencies cited during a complaint investigation survey at Bethany Home.
Complaint Details
The visit was complaint-related, with investigations into allegations of abuse, neglect, and exploitation. The investigation was completed and provided to the state surveyor immediately upon request. All allegations, substantiated or unsubstantiated, are to be reported and monitored.
Findings
The plan outlines corrective actions for deficiencies related to abuse, neglect, exploitation reporting, and resident lifting and transfer procedures, with education and monitoring measures to ensure compliance.
Deficiencies (3)
Deficiencies cited during the survey requiring a credible allegation of substantial compliance.
Failure to properly investigate and report allegations of abuse, neglect, and exploitation.
Inadequate resident lifting and transfer practices requiring immediate change to total sling lift and staff reeducation.
Report Facts
Plan of Correction completion date: Dec 3, 2014
Inservice date: Nov 26, 2014
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 3, 2014
Visit Reason
An abbreviated survey was conducted to determine if the facility is 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 'D' level deficiencies that constitute 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 based on the credible allegation of compliance.
Deficiencies (1)
Deficiencies cited at 'D' level constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Signed letter regarding survey results and plan of correction acceptance |
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 resident safety and supervision related to the use of mechanical lifts.
Complaint Details
The complaint investigation (#80325) was substantiated in part, finding the facility failed to report an allegation of abuse and failed to ensure adequate supervision and safe use of assistive devices, resulting in resident injuries.
Findings
The facility failed to report an allegation of potential abuse by staff involving Resident #3 to the state agency. Additionally, the facility failed to identify physical declines in Residents #1 and #2 that resulted in injuries due to improper use of sit to stand lifts, including significant bruising and pain. Staff training on lift use was limited to initial hire with no ongoing training.
Deficiencies (3)
Failure to report a resident's allegation of potential abuse by staff to the local state agency.
Failure to identify Resident #1's physical decline and inability to safely transfer with the sit to stand lift, resulting in significant bruising and pain.
Failure to identify Resident #2's inability to safely transfer with the sit to stand lift, resulting in a facial bruise.
Report Facts
Census: 87
Sample size: 4
BIMS score: 10
BIMS score: 9
Fall Risk Assessment score: 12
Bruise measurement: 14
Bruise measurement: 7
Bruise measurement: 4
Bruise measurement: 8
Bruise measurement: 4
Bruise measurement: 7
White blood cell count: 14.2
Red blood cell count: 3.27
Bruise measurement: 1.4
Bruise measurement: 1.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse G | Administrative Nurse | Verified facility completed internal investigation and did not report abuse allegation to state agency |
| Administrative Staff H | Administrative Staff | Verified staff did not report abuse allegation to state agency |
| Nurse Aide A | Nurse Aide | Observed resident struggling with sit to stand lift transfers and notified nurse |
| Nurse Aide B | Nurse Aide | Reported resident had problems holding on to sit to stand lift and did not notify nurse of decline |
| Nurse C | Nurse | Identified bruising on resident's arm and stated staff had not notified about transfer difficulties |
| Administrative Staff D | Administrative Staff | Verified staff training on lifts only occurred upon hire with no ongoing training |
| Nurse Aide E | Nurse Aide | Notified nurse of resident leaning during sit to stand lift transfer but did not report due to busy shift |
| Nurse F | Nurse | Reported resident declining and hospice care, but had not personally witnessed transfer problems |
Inspection Report
Follow-Up
Deficiencies: 14
Date: Aug 14, 2014
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.
Findings
The report documents that all previously identified deficiencies listed on the CMS-2567 have been corrected by 07/31/2014.
Deficiencies (14)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.10(i)(1)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4)
Deficiency related to regulation 483.15(b)
Deficiency related to regulation 483.15(g)(1)
Deficiency related to regulation 483.15(h)(2)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(f)(1)
Deficiency related to regulation 483.25(h)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.35(f)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(c)
Report Facts
Deficiencies corrected: 14
Inspection Report
Plan of Correction
Deficiencies: 12
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 taken and planned to address various regulatory compliance issues.
Findings
The plan details corrective actions for multiple deficiencies including medication refusal protocols, mail delivery, incident reporting, resident preferences, depression and mood disorder management, maintenance repairs, elopement prevention, food safety, and chemical storage. The facility has implemented new policies, staff training, and monitoring systems to ensure compliance.
Deficiencies (12)
Medication refusal protocols were implemented including auto alerts and staff inservice.
Mail delivery to residents was ensured Monday through Saturday.
Incident reporting updated to include unwitnessed events with injury and staff inservice.
Resident preferences incorporated into care plans with monitoring.
Depression screening and mood disorder interventions implemented with care plan updates.
Maintenance repairs proceeding with updated QA checklists and staff training.
Care plans updated for elopement risk and siderail use; chemical storage secured.
Care plan meeting invitations sent and logged for family members.
Medication refusal protocols reinforced with auto alerts and staff training.
Snack and beverage offering policy developed and staff educated.
Food safety and sanitation procedures updated including equipment checks and staff education.
Medication management system updated to track refusals and provide reports.
Report Facts
Corrective action completion dates: Jul 10, 2014
Corrective action completion dates: Jul 31, 2014
Corrective action completion dates: Jul 17, 2014
Corrective action completion dates: Jul 22, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Peters | Administrator | Submitted the Plan of Correction |
Inspection Report
Enforcement
Deficiencies: 1
Date: Jul 2, 2014
Visit Reason
A Health survey was conducted by the Kansas Department for Aging and Disability Services 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 in the facility to be a 'G' level. As a result, enforcement remedies including denial of payment for new Medicare admissions effective October 2, 2014, were imposed until substantial compliance is achieved or the provider agreement is terminated.
Deficiencies (1)
Most serious deficiency found to be a 'G' level
Report Facts
Months until termination recommendation: 6
Denial of payment effective date: Oct 2, 2014
Civil Money Penalty threshold: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Peters | Administrator | Named as facility administrator in the report. |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter. |
| Joe Ewert | Commissioner | Recipient of informal dispute resolution requests. |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 13
Date: Jul 2, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #74968, #75410 and #75311.
Complaint Details
The inspection included complaint investigations #74968, #75410, and #75311.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of changes in resident condition, failure to provide privacy in mail handling, failure to report injuries of unknown origin, failure to provide resident choice and preferences, failure to provide medically-related social services, failure to maintain a sanitary environment, failure to develop comprehensive care plans, failure to provide psychosocial and emotional support, failure to prevent accidents and adequately supervise residents, failure to monitor drug regimens and medication refusals, failure to provide evening snacks to all residents, and failure to maintain sanitary food preparation and service.
Deficiencies (13)
Failure to notify physician or responsible party regarding changes in mood, behavior, and refusal of prescribed medications for Resident #100.
Failure to provide right to privacy in written communications including sending and promptly receiving unopened mail for all residents.
Failure to report injuries from unknown origin to State agency for Resident #59.
Failure to provide choices for Resident #85 regarding activities, schedules, and health care.
Failure to provide medically-related social services to maintain highest level of mental and psychosocial functioning for Resident #100.
Failure to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior on Hoglund hall.
Failure to develop comprehensive care plans for Residents #100 and #69.
Failure to invite Resident #85's responsible party to care plan meetings.
Failure to provide care and services to maintain highest level of mental and psychosocial functioning for Resident #100.
Failure to ensure resident environment free of accident hazards and provide adequate supervision for Residents #59 and #69.
Failure to offer snacks at bedtime to Residents #10 and #70.
Failure to store, prepare, distribute, and serve food under sanitary conditions including failure to monitor temperatures, label and date foods, prevent contamination, and maintain a clean environment.
Failure of pharmacy consultant to identify medication irregularities and report to physician or director of nursing regarding Resident #100's refusal of Valproic Acid.
Report Facts
Census: 90
Sample size: 18
Medication refusal period: 85
Side rail gap: 24
Side rail gap: 18
Side rail gap: 13
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, refused to come out of room, and had mental health evaluation |
| Administrative Nurse D | Administrative Nurse | Verified resident #100's increased behaviors and mood changes, unawareness 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, suicidal ideation, and medication refusal |
| Nurse Aide H | Nurse Aide | Verified resident #100 made statements about wishing to die and had asked for a gun |
| Nurse Aide I | Nurse Aide | Verified resident #100 makes statements about being better off dead |
| Nurse J | Nurse | Stated resident #69 was confused with exit seeking behaviors and staff frequently shut off alarms allowing unsupervised exit |
| Nurse Aide K | Nurse Aide | Stated staff shut off front entrance alarm and allowed resident #69 to exit unsupervised |
| Nurse D | Nurse | Verified resident #69 eloped and facility had no care plan to supervise resident outside |
| Housekeeping Staff N | Housekeeping Staff | Verified housekeeping carts must be locked when unattended |
| Administrative Nurse P | Administrative Nurse | Verified 16 cognitively impaired independently mobile residents reside in facility |
| Nurse M | Licensed Nursing Staff | Explained responsibility for inviting family to care plan meetings and lack of documentation of invitations |
| Social Service Staff C | Social Service Staff | Stated resident #85's responsible party did not attend care plan meetings and no documentation of invitations |
| Nurse W | Nurse | Stated not all residents receive evening snacks but staff can provide upon request |
| Dietary Staff F | Dietary Staff | Stated dietary sends snacks routinely but nursing responsible for snack pass completion |
| Dietary Staff T | Dietary Staff | Observed contaminating food during meal service |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 30, 2014
Visit Reason
The document is a resurvey of an Assisted Living/Residential Healthcare facility to verify compliance and check for deficiencies.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Life Safety
Deficiencies: 1
Date: May 15, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance 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)
Most serious deficiency found was an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Aug 15, 2014
Provider agreement termination date: Nov 15, 2014
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 15, 2013
Visit Reason
The health survey was conducted as a routine annual inspection 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 for long term care facilities.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jun 15, 2012
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.
Findings
The report confirms that deficiencies previously cited under regulations 483.35(i) and 483.60(a),(b) have been corrected as of 06/15/2012.
Deficiencies (2)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.60(a),(b)
Report Facts
Deficiencies corrected: 2
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 2
Date: May 9, 2012
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation #55113 at the facility.
Complaint Details
The visit included a complaint investigation #55113. The findings were substantiated as the facility failed to meet sanitary food handling and pharmaceutical service requirements.
Findings
The facility failed to maintain sanitary food preparation and serving practices, including improper hairnet use and handling of residents' glasses. Additionally, the facility failed to monitor expiration dates of stock medications and medications for one resident, potentially exposing residents to outdated medications.
Deficiencies (2)
Failure to prepare and serve beverages and food under sanitary conditions, including incomplete hairnet coverage and improper handling of residents' glasses and coffee cups.
Failure to provide pharmaceutical services with accurate procedures, including failure to monitor expiration dates of stock medications and medications for one resident.
Report Facts
Census: 93
Sample size: 17
Medication carts: 6
Medication carts with expired medications: 2
Expired medication examples: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff A | Verified proper hairnet use and handling of residents' glasses. | |
| Certified Medication Aide E | Verified expired medications on medication carts during observation. | |
| Nurse D | Verified staff responsibilities for monitoring stock medications for expiration. | |
| Nurse B | Stated the facility had no written policy for monitoring outdated medications and described the unwritten policy. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N059001 POC V1IO11
Visit Reason
This document is a Plan of Correction submitted by Bethany Home addressing deficiencies cited related to food sanitation practices and medication management.
Findings
The plan outlines corrective actions including updated policies on food preparation and sanitary practices, implementation of new hair restraints for dietary staff, education and monitoring procedures, and revised medication check practices to ensure expired medications are identified and removed.
Deficiencies (2)
Food procure/store/prepare/serve-sanitary practices not compliant
Medication management practices for checking out-dated resident medications deficient
Report Facts
Complete Date: Jun 15, 2012
Complete Date: Jun 7, 2012
In-service Date: May 23, 2012
Education Completion Date: Jul 1, 2012
Medication Check Date: 7
Medication Check Review Date: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emery Myers | Director of Nursing | Submitted the Plan of Correction and involved in education and oversight of medication management |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: N059001 POC XCVS11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a prior survey related to a complaint investigation at Bethany Home.
Complaint Details
This Plan of Correction is linked to a complaint investigation at Bethany Home dated 08/04/2016.
Findings
The plan addresses deficiencies related to improper use of commercial hot packs/thermal agents by staff, including reeducation, competency checks, and monitoring to ensure compliance with proper procedures.
Deficiencies (1)
Improper use of commercial hot packs/thermal agents by staff.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kriston Erickson | CEO | Submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Irina Strakhova | Modified the Plan of Correction document. |
Viewing
Loading inspection reports...
