Inspection Reports for
Bethel Health Care Center
3001 IVY DRIVE, NORTH NEWTON, KS, 67117-8005
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
10.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
77% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
91% occupied
Based on a August 2017 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 12, 2017
Visit Reason
The visit was a non-compliance revisit to determine if previous deficiencies had been corrected.
Findings
The revisit resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 12, 2017
Visit Reason
The visit was a non-compliance revisit to the facility to determine if previous deficiencies had been corrected.
Findings
The revisit resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B for long term care facilities.
Inspection Report
Enforcement
Deficiencies: 0
Date: Aug 3, 2017
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 level of actual harm that is not immediate jeopardy. Due to these deficiencies, the facility will not be given an opportunity to correct before enforcement remedies are imposed, including denial of payment for new Medicare and Medicaid admissions.
Report Facts
Denial of payment effective date: Aug 27, 2017
Termination recommendation date: Feb 3, 2018
Civil Money Penalty minimum amount: 5000
IDR submission deadline days: 10
Hearing request deadline days: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact person for questions regarding the enforcement letter. |
Inspection Report
Enforcement
Deficiencies: 0
Date: Aug 3, 2017
Visit Reason
A Health survey 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 level of actual harm that is not immediate jeopardy. Based on these deficiencies, the facility will not be given an opportunity to correct before enforcement remedies are imposed, including denial of payment for new Medicare and Medicaid admissions.
Report Facts
Denial of payment effective date: Aug 27, 2017
Termination recommendation date: Feb 3, 2018
Civil Money Penalty minimum amount: 5000
Hearing request deadline days: 60
Informal Dispute Resolution request deadline days: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact person for questions concerning the instructions contained in the letter. |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 6
Date: Aug 3, 2017
Visit Reason
Health Resurvey and Complaint Investigation triggered by allegations of neglect and failure to investigate and report incidents properly.
Complaint Details
The complaint investigation revealed failure to investigate and report an allegation of neglect involving a resident's injury from a wheelchair accident, and failure to implement appropriate interventions after resident falls.
Findings
The facility failed to thoroughly investigate and report an allegation of neglect resulting in injury, failed to revise care plans appropriately after falls, failed to provide adequate supervision and assistive devices to prevent accidents, failed to post accurate nurse staffing data, failed to maintain sanitary food service conditions, and failed to maintain a safe and sanitary environment.
Deficiencies (6)
F225: Facility failed to thoroughly investigate and report an allegation of neglect involving a resident's injury from a wheelchair accident.
F280: Facility failed to review and revise the care plan with appropriate interventions for a cognitively impaired resident who sustained falls.
F323: Facility failed to provide adequate supervision and assistive devices to prevent accidents for 3 of 4 residents reviewed, including improper transfer resulting in a fractured ankle and failure to prevent falls.
F356: Facility failed to post daily nurse staffing data with actual hours worked as required by regulation.
F371: Facility failed to store, prepare, distribute, and serve food under sanitary conditions, including dirty equipment, unclean surfaces, and lack of cleaning documentation.
F465: Facility failed to provide a safe, functional, sanitary, and comfortable environment, including failure to maintain kitchen floor sanitation resulting in debris and liquid buildup.
Report Facts
Resident census: 59
Residents reviewed: 14
Residents reviewed for accidents: 4
Fall assessment score: 9
Fall assessment score: 18
Staffing scheduled: 6
Staffing actual hours: 45.5
Inspection Report
Life Safety
Deficiencies: 1
Date: Jan 5, 2017
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 at an 'F' level, indicating no harm but with potential for more than minimal harm that is 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 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: Apr 5, 2017
Effective date for provider agreement termination: Jul 5, 2017
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the survey results letter. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 5, 2017
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. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 18, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at Bethel Health Care.
Complaint Details
This Plan of Correction relates to a complaint investigation at Bethel Health Care dated 02/23/2016.
Findings
The plan addresses medication administration errors involving a medication aide who was terminated, monitoring and treatment of the affected resident, and updates to policies and staff education to prevent recurrence.
Deficiencies (1)
S3026-G: Medication aide incorrectly administered medications resulting in resident monitoring and ER evaluation. Staff received counseling and policies were updated to improve medication administration procedures.
Report Facts
Date of medication aide termination: Feb 4, 2016
Plan completion date: Mar 18, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Linda Peters | Administrator | Submitted the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 1
Date: Feb 23, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#96719) regarding medication errors and resident safety.
Complaint Details
Complaint investigation #96719 substantiated the medication error and inadequate monitoring of vital signs, leading to resident harm and hospitalization.
Findings
The facility failed to prevent significant medication errors when one resident received another resident's medications, resulting in adverse reactions and hospitalization. Staff did not monitor vital signs hourly as ordered by the physician, contributing to delayed response to the resident's deteriorating condition.
Deficiencies (1)
26-41-101 (f) (1) Staff Treatment of Residents ANE: The facility failed to ensure a resident remained free of medication errors when the resident received nine medications belonging to another resident, causing adverse reactions and hospitalization. Staff did not monitor vital signs hourly as ordered by the physician.
Report Facts
Resident census: 22
Medications received in error: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Nursing Staff / Charge Nurse | Named in relation to failure to document assessments and vital signs after medication error. |
| Staff B | Administrative Nursing Staff | Named regarding expectations for nurse documentation and assessment after medication error. |
| Staff D | Direct Care Staff | Named as staff who took blood pressures and reported to nurse on the night of the incident. |
| Physician E | Physician | Provided medical assessment and treatment related to the medication error incident. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jan 14, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2015-12-16.
Findings
The report confirms that the previously identified deficiency with regulation 483.25(d) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.25(d) deficiency was corrected as of 2016-01-14.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jan 14, 2016
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at Bethel Health Care Centre.
Findings
The report confirms that the previously identified deficiency under regulation 28-39-158(a) with ID prefix S0600 was corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency previously cited was corrected by the revisit date of 2016-01-14.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jan 14, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2015-12-16.
Findings
The report confirms that the previously identified deficiency under regulation 483.25(d) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.25(d) deficiency was corrected by 2016-01-14 as verified during the revisit.
Report Facts
Deficiency correction date: Jan 14, 2016
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jan 14, 2016
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that previously identified deficiencies have been corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency previously cited under ID prefix S0600 was corrected by 2016-01-14.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jan 14, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified during a prior inspection.
Findings
The facility identified deficiencies related to urinary catheter care and dietary manager certification. Corrective actions include staff education, competency evaluations, and certification progress monitoring.
Deficiencies (2)
F315-D: The facility had deficient practices in handling urinary catheters, requiring staff education and competency evaluation. No further incidents were reported after corrective actions.
S600-C: The dietary manager was not yet certified but was enrolled in an approved certification program with supervision and support in place. Completion was expected by July 2016.
Inspection Report
Renewal
Deficiencies: 0
Date: Dec 16, 2015
Visit Reason
The licensure resurvey was conducted to assess compliance for continued program participation and renewal of the facility's license.
Findings
The licensure resurvey resulted in a finding of no deficiency citations.
Inspection Report
Enforcement
Deficiencies: 1
Date: Dec 16, 2015
Visit Reason
The inspection was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a most serious deficiency at a 'D' level, isolated, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective January 14, 2016.
Deficiencies (1)
A 'D' level deficiency was cited, isolated, 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 letter regarding the survey findings and plan of correction. |
Inspection Report
Enforcement
Deficiencies: 1
Date: Dec 16, 2015
Visit Reason
The 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 a most serious deficiency at level "D", isolated, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective January 14, 2016.
Deficiencies (1)
A level "D" deficiency was cited, isolated, 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 | Named as Enforcement Coordinator in the report. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 16, 2015
Visit Reason
This document is a Plan of Correction submitted in response to a deficiency report for the facility Bethel ALF2 dated 12/16/2015.
Findings
No deficiencies were cited in the survey as indicated by the 'No deficiency survey' status.
Deficiencies (1)
No deficiency survey was conducted on 12/16/2015.
Inspection Report
Re-Inspection
Census: 57
Deficiencies: 1
Date: Dec 16, 2015
Visit Reason
The inspection was a Health Resurvey to assess compliance with dietary services regulations.
Findings
The facility failed to retain a full-time certified dietary manager to oversee the dietary department. The current dietary manager lacked certification and was not in training at the time of inspection.
Deficiencies (1)
28-39-158(a) Dietary services. The facility failed to employ a full-time certified dietary manager to oversee the dietary department for residents. The current dietary manager lacked certification and was not in training.
Report Facts
Resident census: 57
Inspection Report
Life Safety
Deficiencies: 1
Date: Sep 16, 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 isolated 'D' level deficiencies with no harm but potential for more than minimal harm, not constituting immediate jeopardy.
Deficiencies (1)
The facility was cited for 'D' level deficiencies in Life Safety Code compliance, isolated with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Dec 16, 2015
Provider agreement termination date: Mar 16, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding Life Safety Code survey results. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Sep 16, 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 isolated 'D' level deficiencies with no harm but potential for more than minimal harm, not constituting immediate jeopardy.
Deficiencies (1)
The facility was cited for 'D' level deficiencies related to Life Safety Code compliance. These deficiencies were isolated and posed no immediate jeopardy but had potential for more than minimal harm.
Report Facts
Effective date for denial of payments: Dec 16, 2015
Provider agreement termination date: Mar 16, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the Life Safety Code survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process related to cited deficiencies. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Oct 6, 2014
Visit Reason
This visit was 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 report confirms that the deficiencies previously reported under regulations 483.25(h) and 483.25(m)(2) were corrected as of the revisit date.
Deficiencies (2)
Regulation 483.25(h): Previously cited deficiency was corrected by the revisit date.
Regulation 483.25(m)(2): Previously cited deficiency was corrected by the revisit date.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Oct 6, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies had been corrected.
Findings
The report confirms that the deficiencies previously cited under regulations 483.25(h) and 483.25(m)(2) were corrected as of the revisit date.
Deficiencies (2)
Regulation 483.25(h): Previously cited deficiency was corrected by the revisit date.
Regulation 483.25(m)(2): Previously cited deficiency was corrected by the revisit date.
Inspection Report
Enforcement
Deficiencies: 1
Date: Sep 12, 2014
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 deficiency 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, resulting in a finding of substantial compliance effective October 6, 2014.
Deficiencies (1)
The facility had an "E" level deficiency pattern constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Sep 12, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified during a prior inspection.
Findings
The facility identified deficiencies related to bed rails exceeding FDA recommended spacing and medication administration practices. Corrective actions include ordering space-filling devices for bed rails and staff education on medication administration standards.
Deficiencies (2)
F323: Beds with side rails have open spaces exceeding the FDA recommended 4.75 inches. Space-filling devices were ordered and will be installed on all identified side rails.
F333: Medication administration did not follow physician-ordered parameters. The CMA was educated and supervised to ensure proper protocol was followed.
Report Facts
Complete Date for F323 corrective actions: Oct 6, 2014
Complete Date for F333 corrective actions: Oct 6, 2014
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 2
Date: Sep 12, 2014
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #74829 to assess compliance with safety and medication administration regulations.
Complaint Details
The visit was triggered by Complaint Investigation #74829. The complaint was substantiated as the facility failed to maintain safe bed rails and properly follow medication orders.
Findings
The facility failed to ensure resident beds were free of entrapment hazards due to side rails with open spaces greater than 4 and 3/4 inches. Additionally, the facility failed to follow physician orders for medication administration, resulting in a significant medication error involving blood pressure medication.
Deficiencies (2)
F 323: The facility failed to ensure side rails on 17 resident beds had open spaces less than 4 and 3/4 inches to prevent entrapment hazards.
F 333: The facility failed to follow physician orders for resident #65, resulting in administration of blood pressure medication when systolic pressure was below the ordered threshold, causing a significant medication error.
Report Facts
Census: 60
Resident beds with side rails having open spaces greater than 4 and 3/4 inches: 17
Residents selected for medication review: 18
Inspection Report
Re-Inspection
Census: 26
Deficiencies: 1
Date: Sep 12, 2014
Visit Reason
The visit was a Health Licensure Resurvey to assess compliance with staffing requirements for the assisted living unit.
Findings
The facility failed to provide continuous qualified nursing staff attendance for the 26 residents of the assisted living unit during the 10:30 pm to 6:00 am shift. Staffing schedules showed no staff assigned overnight, and the assisted living unit was locked with residents having keypad access.
Deficiencies (1)
39-936 (b) The facility failed to provide nursing staff attendance at all times for the 26 residents of assisted living, specifically lacking staff scheduled from 10:30 pm to 6:00 am.
Report Facts
Resident census: 26
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Sep 12, 2014
Visit Reason
The plan of correction addresses deficiencies related to fire door safety and staffing in the assisted living wing, following a prior inspection.
Findings
The facility immediately abated concerns by scheduling nursing staff for overnight shifts and implementing fire door modifications. Staff will conduct regular rounds every two hours, and documentation and monitoring of these rounds will be maintained.
Deficiencies (3)
Fire doors separating the assisted living wing from the skilled nursing facility wing were not properly managed overnight. The facility corrected this by installing magnetic holders to keep doors open from 10 pm to 6 am daily.
Staffing was insufficient overnight in the assisted living wing. A nursing staff member was scheduled for the 10 pm to 6 am shift to address this issue.
Nursing staff were not consistently documenting scheduled and unscheduled rounds. The facility implemented documentation of rounds every two hours and will monitor compliance weekly and quarterly.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 2, 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 had been corrected.
Findings
The report confirms that the previously cited deficiency with regulation 483.25(h) was corrected as of 08/01/2014. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 483.25(h) deficiency was corrected on 08/01/2014 as verified during this revisit.
Report Facts
Deficiencies corrected: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 1, 2014
Visit Reason
This document is a plan of correction submitted in response to a complaint investigation at Bethel Health Care.
Complaint Details
This plan of correction is related to a complaint investigation at Bethel Health Care.
Findings
The plan addresses a deficiency related to improper use of safety belts on bathing chairs. The facility implemented staff counseling, in-service training, and monitoring procedures to ensure compliance.
Deficiencies (1)
F323-G: The safety belt on bathing chairs was not properly installed and fitted, posing a safety risk. Staff were counseled and trained on proper use and monitoring of bathing safety equipment was instituted.
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Date: Jul 30, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#76382) regarding the facility's failure to ensure a safe environment and proper use of safety equipment during resident transfers in and out of the whirlpool bathtub.
Complaint Details
This visit was triggered by complaint investigation #76382. The complaint was substantiated as the facility failed to ensure proper use of safety equipment, leading to a resident fall with major injury.
Findings
The facility failed to provide a safe environment for resident #1 by not having a system in place to assure proper use of safety belts during transfers in and out of the whirlpool bathtub, resulting in a fall and three fractured vertebrae. Staff reported inconsistent use and availability of the safety belts, lack of training, and recent introduction of manuals and belts after the incident.
Deficiencies (1)
F 323 483.25(h) The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision or use of assistance devices, resulting in a resident falling from a whirlpool tub lift chair without a safety belt and sustaining three fractured vertebrae.
Report Facts
Resident census: 60
Residents using whirlpool bathtubs: 42
Residents reviewed for accidents: 3
Fall Risk Assessment score: 17
Pain rating: 7
Date of resident fall: Jun 12, 2014
Inspection Report
Life Safety
Deficiencies: 1
Date: Feb 10, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found isolated 'D' level deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility had isolated 'D' level deficiencies indicating potential for more than minimal harm without immediate jeopardy.
Report Facts
Effective date for denial of payments: May 10, 2014
Provider agreement termination date: Aug 10, 2014
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Survey, Certification and Credentialing Commission. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Life Safety
Deficiencies: 1
Date: Feb 10, 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 isolated 'D' level deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
The facility was cited for isolated 'D' level deficiencies indicating no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: May 10, 2014
Provider agreement termination date: Aug 10, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Survey, Certification and Credentialing Commission. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jun 22, 2013
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
The report confirms that all deficiencies previously reported on the CMS-2567 have been corrected as of the revisit date.
Deficiencies (4)
Regulation 483.25(h): Previously cited deficiency corrected as of 06/22/2013.
Regulation 483.25(l): Previously cited deficiency corrected as of 06/22/2013.
Regulation 483.35(d)(1)-(2): Previously cited deficiency corrected as of 06/22/2013.
Regulation 483.70(f): Previously cited deficiency corrected as of 06/22/2013.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 22, 2013
Visit Reason
This is 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 all previously reported deficiencies under regulations 483.25(h), 483.25(l), 483.35(d)(1)-(2), and 483.70(f) were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jun 21, 2013
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at the facility.
Findings
The report documents that previously identified deficiencies with regulation numbers 28-39-254 and 28-39-256 were corrected as of the revisit date.
Deficiencies (2)
Regulation 28-39-254 deficiency was corrected by 06/21/2013.
Regulation 28-39-256 deficiency was corrected by 06/21/2013.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jun 21, 2013
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at Bethel Health Care Centre.
Findings
The report documents that previously cited deficiencies identified by regulation numbers 28-39-254 and 28-39-256 were corrected as of the revisit date.
Deficiencies (2)
Regulation 28-39-254 deficiency was corrected by 06/21/2013.
Regulation 28-39-256 deficiency was corrected by 06/21/2013.
Inspection Report
Re-Inspection
Census: 59
Deficiencies: 4
Date: May 23, 2013
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously cited deficiencies and regulatory requirements.
Findings
The facility failed to maintain safe water temperatures and secure the North hall satellite kitchen, failed to develop comprehensive care plans addressing black box warnings for multiple residents on psychotropic medications, failed to prepare pureed foods properly to conserve nutritive value and appearance, and failed to maintain a functioning resident call light system that reliably alerted staff.
Deficiencies (4)
F 323: The facility failed to test and maintain safe water temperatures in the North hall satellite kitchen and failed to secure the kitchen door, posing a burn risk to residents.
F 329: The facility failed to develop comprehensive care plans addressing black box warnings for 10 of 31 sampled residents receiving psychotropic and other medications.
F 364: The facility failed to prepare pureed foods to conserve nutritive value, flavor, and appearance, using water instead of broth and not compensating for preformed pureed bread.
F 463: The facility failed to maintain a functioning call light system that reliably paged direct care staff, resulting in delayed response to resident calls.
Report Facts
Facility census: 59
Residents sampled for care plan review: 31
Call light activation duration: 358
Residents receiving pureed diet: 2
Residents with black box warning care plan deficiencies: 10
Inspection Report
Renewal
Census: 25
Deficiencies: 2
Date: May 23, 2013
Visit Reason
The inspection was a Licensure Resurvey to assess compliance with regulatory requirements for the assisted living facility.
Findings
The facility failed to ensure a safe environment by improperly storing hazardous chemicals accessible to cognitively impaired residents and failed to monitor and maintain safe water temperatures in the dining room sink, posing potential risks to all residents.
Deficiencies (2)
28-39-254 CONSTRUCTION: The facility failed to provide a safe, sanitary, and comfortable environment by storing hazardous chemicals such as Virex 256 and Barbicide in unlocked areas accessible to residents with cognitive impairments.
28-39-256 MECHANICAL REQUIREMENTS: The facility failed to monitor and maintain safe water temperatures, with the dining room sink water temperature reaching up to 135.5°F, exceeding the safe maximum of 120°F and risking burn injuries to residents.
Report Facts
Resident census: 25
Water temperature: 135.5
Water temperature: 129.9
Cognitively impaired residents: 13
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N040001 POC
Visit Reason
This document is a Plan of Correction related to a facility identified by State ID N040001, intended to address deficiencies noted in a prior inspection.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction process.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: N040001 POC 87SY11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection report.
Findings
The plan outlines corrective actions taken or to be taken to address issues related to resident care, fall prevention, mechanical lift use, nurse staffing information posting, and kitchen cleanliness.
Deficiencies (6)
F225-D: The facility revised the care plan for a resident to include pain treatment, foot wrapping, elevation, and proper foot placement to keep the resident safe.
F280-D: The facility recognized not all falls are preventable and revised care plans with interventions to mitigate falls, including assessments and medication reviews.
F323-G: The facility implemented use of mechanical lifts for transfers, revised training for staff, and updated care plans for residents with fractures and mobility issues.
F356-C: The facility reviewed and educated staff on nurse staffing information posting policies and will conduct audits to ensure compliance.
F371-F: The facility replaced or cleaned various kitchen equipment and updated cleaning logs and audit procedures to maintain sanitation.
F465-E: The facility updated floor cleaning policies and scheduled deep cleaning of kitchen floors with audits overseen by housekeeping.
Report Facts
Corrective action completion date: Aug 17, 2017
Corrective action completion date: Aug 24, 2017
Corrective action completion date: Aug 8, 2017
Corrective action completion date: Aug 31, 2017
Corrective action completion date: Aug 10, 2018
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N040001 POC CX7H11
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified as CX7H11 for the facility with State ID N040001.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Document
Deficiencies: 0
Date: N040001 POC XHJN11
Visit Reason
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Findings
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