Deficiencies (last 3 years)
Deficiencies (over 3 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% better than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
78 residents
Based on a April 2024 inspection.
Occupancy over time
Inspection Report
Routine
Census: 78
Deficiencies: 5
Date: Apr 4, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, notification of Medicare/Medicaid coverage, transfer/discharge notifications, psychotropic medication use, and antibiotic monitoring at Bethany Nursing Home.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining assistance, failure to provide required Medicare beneficiary notices, failure to notify the ombudsman of resident transfers/discharges, lack of specific duration orders for PRN psychotropic medications, and failure to monitor prophylactic antibiotic use.
Deficiencies (5)
Failed to provide a dignified dining experience for Resident #68, including staff standing beside rather than sitting next to the resident while feeding.
Failed to provide Residents #72 and #73 with Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) informing them of financial liability for services not covered by Medicare.
Failed to ensure the ombudsman was notified in writing of resident transfers/discharges for three residents (#2, #79, #80).
Failed to ensure psychotropic medications ordered on an as needed basis had a specific duration for use, affecting Residents #26 and #335.
Failed to implement a program that monitors antibiotic use, specifically prophylactic antibiotic use, affecting Residents #23 and #36.
Report Facts
Facility census: 78
Residents transferred/discharged since January 2024: 52
Residents reviewed for beneficiary notification: 3
Residents reviewed for medical necessity of medication use: 6
Residents reviewed for antibiotic use: 2
Residents reviewed for unnecessary medications: 5
Trazodone administrations: 13
Ativan doses administered: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA #502 | State Tested Nurse Aide | Assisted Resident #68 with feeding while standing beside the resident |
| Director of Nursing | Director of Nursing (DON) | Provided interviews regarding feeding assistance expectations, psychotropic medication orders, antibiotic monitoring, and facility policies |
| Administrator | Facility Administrator | Verified failure to provide SNF ABN forms and failure to notify ombudsman of transfers/discharges |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Date: Jun 8, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report allegations of abuse involving Resident #3.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00143450. The facility did not report the incident involving STNA #556 slapping Resident #3 to the State Agency as required.
Findings
The facility failed to timely report suspected abuse when STNA #556 was observed slapping Resident #3's arm. Multiple staff interviews revealed conflicting accounts, and the facility was unable to determine if abuse actually occurred. The Administrator acknowledged that the incident should have been reported to the State Agency as a self-reported incident.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents Affected: 1
Facility Census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator #511 | Administrator | Interviewed regarding the incident and reporting responsibilities |
| STNA #605 | State Tested Nursing Assistant | Reported witnessing STNA #556 slap Resident #3 and reported the concern |
| STNA #556 | State Tested Nursing Assistant | Alleged to have slapped Resident #3 |
| LPN #551 | Licensed Practical Nurse | Interviewed and demonstrated how Resident #3 was assisted back to her seat |
| RA #681 | Resident Assistant | Interviewed; heard about inappropriate contact but did not witness the slap |
| EDQ/RN #614 | Executive Director of Quality / Registered Nurse | Interviewed and involved in incident investigation |
| FM #508 | Facility Manager | Interviewed regarding the incident |
| AA #541 | Administrative Assistant | Received report from STNA #605 and involved in reporting process |
| ADON/LPN #510 | Assistant Director of Nursing / Licensed Practical Nurse | Interviewed regarding discrepancies in incident investigation |
| DON | Director of Nursing | Interviewed regarding incident investigation and reporting responsibilities |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 3
Date: Jun 8, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to properly screen employees for abuse history, failure to timely report suspected abuse, and inaccurate resident assessments.
Complaint Details
The complaint investigation involved allegations of failure to screen employees for abuse history, failure to timely report suspected abuse of Resident #3, and inaccurate resident assessments. The facility census was 81 residents. The abuse incident involved STNA #556 allegedly slapping Resident #3, which was reported by STNA #605 but was not reported to the State Agency by the facility. The investigation was inconclusive regarding abuse occurrence.
Findings
The facility failed to implement abuse screening policies for employees, failed to timely report an alleged abuse incident involving a resident, and failed to ensure accurate Minimum Data Set (MDS) assessments for residents. The abuse incident investigation was inconclusive, and discrepancies were noted in staff statements.
Deficiencies (3)
Failure to effectively implement abuse policy and procedure to ensure employees were properly screened against the State of Ohio Nurse Aide Registry upon hire.
Failure to timely report allegations of abuse to the State Agency involving one resident.
Failure to ensure assessments were accurately completed for residents, including incorrect documentation of pressure ulcers and functional status.
Report Facts
Residents affected: 81
Residents reviewed for MDS assessments: 21
Residents affected by inaccurate assessments: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator #511 | Administrator | Involved in abuse incident investigation and reporting |
| Facility Manager #508 | Facility Manager | Involved in abuse incident investigation |
| Human Resource Manager #508 | Human Resource Manager | Confirmed failure to check Nurse Aide Registry upon hire |
| STNA #605 | State Tested Nursing Assistant | Reported alleged abuse of Resident #3 |
| STNA #556 | State Tested Nursing Assistant | Alleged to have slapped Resident #3 |
| LPN #551 | Licensed Practical Nurse | Demonstrated manner of assisting Resident #3 during incident |
| RN #614 | Registered Nurse, Executive Director of Quality | Documented skin assessment and involved in abuse incident investigation |
| RA #681 | Resident Assistant | Witness in abuse incident investigation |
| Assistant Director of Nursing (ADON)/LPN #510 | Assistant Director of Nursing | Interviewed regarding abuse incident investigation |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding abuse incident investigation and reporting |
| Administrative Assistant (AA) #541 | Administrative Assistant | Received abuse report from STNA #605 |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 12, 2020
Visit Reason
The document is an annual inspection report for Bethany Nursing Home, Inc., summarizing the findings of the survey conducted on 2020-03-12.
Findings
No health deficiencies were found during the inspection.
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