Inspection Reports for
Bethany Lutheran Home

The complaint investigation substantiated immediate jeopardy related to Resident #38's elopement on 7/20/25 and identified multiple residents experiencing delayed call light responses. The immediate jeopardy was removed on 7/21/25 after staff training and policy reinforcement.

The facility failed to prevent elopement of a cognitively impaired resident who wandered outside unsupervised, creating immediate jeopardy to resident safety. Additionally, the facility failed to provide timely nursing staff response to call lights for multiple residents, with documented delays exceeding 15 minutes.

The inspection included investigation of complaints #1657218-C, #2607003-C, #2632458-C, and a facility reported incident #2568153-I, all of which resulted in deficiencies.

The facility was found deficient in several areas including failure to complete a significant change assessment, coordination of PASARR assessments, development and implementation of comprehensive care plans, provision of professional standards in services, free of accident hazards, sufficient nursing staff, and infection prevention and control. Multiple residents showed declines or risks that were not adequately addressed in care plans or assessments.

The facility failed to complete significant change assessments, pre-admission screening and resident review (PASRR), comprehensive care plans for high-risk medications, timely response to call lights, proper medication administration, infection prevention practices, and adequate supervision to prevent elopement. Water management logs were incomplete.

The complaint investigation found substantiated failures related to medication administration and transfer assistance. Resident #2 experienced opioid withdrawal due to failure to renew morphine orders, and Resident #3 was injured due to inadequate transfer assistance.

The facility failed to ensure morphine orders for Resident #2 were implemented after a 30-day review, causing withdrawal symptoms and an emergency room visit. The facility also failed to provide adequate transfer assistance to Resident #3, resulting in injury to the resident's toe.

The deficiencies resulted from investigation of complaints #127962-C, #127968-C, and facility reported incident #128348-I. Complaint #127968-C and incident #128348-I resulted in deficiencies. The facility corrected the deficiencies at the time of the survey; therefore, a plan of correction was not required.

The facility failed to ensure the implementation of a morphine order for Resident #2 after a 30-day review, resulting in withdrawal symptoms and an emergency room visit. Additionally, the facility failed to transfer Resident #3 safely, resulting in injury to the resident's toe due to improper use of mechanical lift and inadequate staff assistance.

The complaint investigation was triggered by allegations that Resident #3 was forcibly medicated without consent and that the facility failed to report the abuse allegation within the required 2-hour timeframe. The investigation substantiated these allegations.

The facility failed to treat Resident #3 with dignity during medication administration by forcibly administering medications without consent. The facility also failed to report an allegation of abuse involving Resident #3 within 2 hours. Additionally, the facility failed to review and revise care plans for Residents #5 and #6 to reflect current needs and interventions.

Complaints #126615-C and #126722-C were substantiated. Facility reported incident #125671-I was substantiated. The investigation revealed failure to treat Resident #3 with dignity, failure to report abuse allegations timely, and failure to revise care plans for residents with significant changes.

Complaints #126615-C and #126722-C and facility reported incident #125671-I were substantiated. The facility failed to treat Resident #3 with dignity during medication administration and failed to report an allegation of abuse involving Resident #3 within required timeframes. The facility also failed to revise care plans for residents with significant changes and failed to ensure residents' rights were protected.

The facility was found to have multiple deficiencies including failure to assess residents for self-administration of medications, failure to implement a tracking system for residents' laundered clothing, failure to provide choice in shower frequency, failure to maintain accurate accounting and records of personal funds, failure to provide proper notice before transfer or discharge, failure to ensure accuracy of resident assessments, failure to develop and implement comprehensive care plans, failure to maintain infection preventionist training, and failure to properly manage bed rails and respiratory care equipment.

Facility reported incident #124207-I was investigated and found not substantiated.

The facility was found not in compliance with several requirements including failure to notify the Long-Term Care Ombudsman of resident transfers, failure to offer bed hold notices, failure to coordinate PASARR assessments, insufficient nursing staff and RN coverage, inadequate dementia care planning, improper food handling and infection control practices.

The facility was found deficient in timely notification of hospital transfers, bed hold notifications, PASRR referrals, nursing staffing levels, call light response times, dementia care planning, food handling practices, and infection prevention protocols.

The complaint investigation substantiated that the facility failed to follow the care plan for Resident #1 requiring two staff for repositioning. Staff A assisted alone, leading to the resident falling and sustaining a fracture. The facility acknowledged the failure and initiated staff education.

The facility failed to follow the care plan for Resident #1 who required two staff for repositioning in bed, leading to the resident falling out of bed and sustaining a fractured left femoral neck. Staff interviews and record reviews confirmed the care plan was not followed and staff were not adequately informed.

Complaint #112185-C was substantiated with no deficiency. Facility reported incident #122255-I was substantiated.

The facility was found to have deficiencies related to failure to follow the care plan for Resident #1, resulting in a fall and injury. The facility failed to provide adequate supervision and assistance with repositioning, leading to a resident fall and subsequent fracture. The facility provided a plan of correction including audits and staff education.

The investigation was complaint-driven, triggered by allegations of improper treatment and unsafe transfers. The complaints were substantiated as the facility failed to provide dignity and safe care to residents.

The facility failed to treat 5 residents with dignity and respect during bathing and transfers, including exposing residents inappropriately and refusing assistance. The facility also failed to ensure safe transfers using mechanical lifts with adequate staff, resulting in potential harm to residents.

Complaints #120633-C and #120634-C were substantiated. Facility reported incidents #119386-1, #120639-1, #120640-1, and #120641-1 were substantiated.

The facility failed to treat 5 residents with dignity and respect during transfers and showers, and failed to provide adequate supervision and assistance during mechanical lift transfers for 2 residents, resulting in substantiated complaints and incidents.

The complaint investigation revealed that Resident #1 was given Oxycodone as ordered but was found unresponsive at a clinic appointment with dangerously low vital signs. The nurse failed to assess or intervene despite family concerns. Immediate Jeopardy was identified on October 20, 2023, and removed on November 1, 2023, after staff education and policy reinforcement.

The facility failed to follow physician orders for medication administration and did not properly assess or intervene when Resident #1 showed signs of unresponsiveness after receiving Oxycodone. Immediate Jeopardy was identified due to inadequate nursing assessments and failure to notify physicians of changes in condition, which was later removed after corrective actions and staff re-education.

Complaint #116541-C and #116581-C were substantiated. Immediate Jeopardy was identified starting October 20, 2023 and removed on November 1, 2023 after corrective actions were implemented.

The facility failed to follow physician orders for medication administration and failed to properly assess and intervene when a resident became unresponsive after receiving Oxycodone. The resident was transported to the emergency room after Narcan administration due to suspected overdose. The facility was cited for not completing assessments and notifying physicians of changes in condition as required by professional standards.

The visit included investigation of complaints #111765-C, #111884-C, #111890-C, #113791-C, #114562-C, and #114728-C. Complaints #111765-C, #111884-C, #111890-C, #113791-C, and #114562-C were substantiated. Complaint #114728-C was not substantiated. Facility reported incidents #113220-I and #114555-I were substantiated.

The facility was found deficient in multiple areas including resident privacy during personal care, grievance handling, bed hold policy compliance, comprehensive care planning, quality of care related to positioning, pressure ulcer treatment, accident prevention and supervision, catheter and incontinence care, respiratory care, dialysis services, sufficient nursing staff, medication administration, and infection prevention and control.

The facility had multiple deficiencies including failure to provide privacy during personal care, inadequate grievance follow-up, failure to obtain timely bed holds, incomplete care plans, failure to adhere to professional standards in medication and respiratory care, improper wheelchair positioning, inadequate pressure ulcer care, failure to prevent accidents and falls, medication errors, delayed call light responses, and lapses in infection control practices.

The facility was found deficient in multiple areas including resident privacy during personal care, grievance handling, comprehensive care planning, professional standards adherence, proper resident positioning, pressure ulcer care, fall prevention and supervision, catheter and incontinence care, respiratory care, dialysis care, call light response times, and medication administration.

The investigation involved complaints 110843-C, 110852-C, 110848-C, 111233-C, 111300-C, and 111409-C, and a facility reported incident 110891-I. Complaints 110843-C, 110852-C, 110848-C, 111300-C, and 111409-C were substantiated, while complaint 111233-C was not substantiated.

The facility was found to have multiple deficiencies related to resident rights, abuse prevention, oral care, quality of care, and pressure ulcer prevention. Several complaints were substantiated, including failure to treat residents with dignity and respect, failure to investigate abuse allegations thoroughly, and inadequate oral and skin care. The facility was found to be in compliance with COVID-19 infection control requirements.

The investigation was complaint-driven, triggered by allegations of staff mistreatment, abuse, neglect, and failure to provide appropriate care to residents. The complaints were substantiated leading to staff termination and findings of deficiencies.

The facility failed to treat residents with dignity and respect, did not fully investigate abuse allegations, failed to provide adequate oral care, did not complete required COVID-19 assessments for positive residents, and failed to properly assess and document pressure ulcers including following hospice orders.

The investigation involved complaints 108448-C (not substantiated), 108599-C (substantiated), and 109186-C (substantiated).

The facility was found to have deficiencies related to failure to develop and implement comprehensive care plans, failure to obtain vital signs daily as required, failure to complete pre and post dialysis assessments, and failure to ensure residents were free of significant medication errors. Immediate Jeopardy was identified but later removed after corrective actions.

Complaints 106459-C, 106881-C, 107421-C, and 107660-C and facility reported incidents 105318-I and 107641-I were substantiated. Complaint 105482-C was not substantiated. Facility reported incident 105366-I was not substantiated.

The facility was found deficient in meeting professional standards related to medication administration and resident care, including failure to ensure staff followed physician orders for medications and failure to provide resident-centered care and services. Several residents' care plans and clinical records lacked proper documentation and assessments.

Complaint #105020-C was substantiated. Complaints #104948-C, #105148-C, #105163-C, and #105197-C were not substantiated.

The facility failed to ensure quality of care related to a resident fall and subsequent injury, and failed to provide sufficient nursing staff to answer call lights in a timely manner. Infection prevention and control deficiencies were also identified, including improper mask usage and failure to follow infection control guidelines. The facility reported a census of 77 residents.

Complaints 104771 and 104908 were substantiated.

The facility was found not in substantial compliance with 42 CFR 483 subpart B, with deficiencies related to failure to determine residents' advanced directives, improper Medicaid/Medicare coverage notices, incomplete comprehensive care plans, inadequate bed rail assessments, and lack of a certified infection preventionist. The facility failed to meet requirements for documentation, resident rights, and infection control.

The investigation involved five complaints (102594-C, 103686-C, 103712-C, 103742-C, and 103744-C), all of which were substantiated. Complaints included failure to follow physician orders, insufficient staffing, and failure to respond to call lights in a timely manner.

The facility failed to follow physician orders for two residents, failed to provide sufficient nursing staff to ensure timely response to call lights and adequate eating assistance for residents, and had substantiated complaints related to these issues. Specific deficiencies included failure to administer nutritional supplements and treatments, failure to provide timely toileting assistance, and inadequate staffing levels.

The visit was a first revisit related to multiple complaints. The facility was found noncompliant in bathing services and safe wheelchair use. The complaints were substantiated based on record reviews, observations, and staff interviews.

The facility failed to provide adequate bathing opportunities for residents, with documentation showing residents refused or were not offered baths on scheduled days. Additionally, the facility failed to ensure a safe environment when transporting residents in wheelchairs without foot pedals, and staff failed to properly use and audit wheelchair foot pedals. Staff education and audits were initiated to address these issues.

Complaints 90477-C, 92266-C, 94717-C, 95012-C, 96000-C, 96434-C, 97328-C, 99473-C, and facility reported incidents 92298-I, 95854-M, 99146-I, 99453-I, 99692-I, 100109-I, 100449-I were substantiated.

The investigation substantiated multiple complaints regarding failure to provide incontinence care, transfer and assistance in a kind and considerate manner, and failure to provide dignity bags for urinary drainage bags. Additional findings included inadequate bathing assistance and supervision, rough handling of residents, and failure to prevent accidents and wandering risks.

The facility was found not in compliance with infection prevention and control requirements, including failure of staff to wear appropriate Personal Protective Equipment (PPE) while cleaning resident rooms on the Skyline Yellow unit. The facility reported 18 positive COVID-19 cases at the time of the survey.

Complaint 86903-C and facility reported incident 89153-1 were substantiated. Complaints 88172-C, 89184-C, and 87905-C were not substantiated.

The facility was found deficient in updating advanced directive statuses, notifying physicians and representatives of significant changes, maintaining accurate assessments, ensuring infection control practices, and providing adequate supervision to prevent accidents. Several residents had discrepancies in code status documentation, delayed antibiotic initiation, inaccurate MDS documentation, and pressure ulcer care issues.