Inspection Reports for Bethel Health Care Center
3001 IVY DRIVE, KS, 67117-8005
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 12, 2017, found no deficiencies upon revisit to verify correction of prior issues. Earlier inspections showed a pattern of deficiencies related mainly to resident care, including fall prevention and supervision, medication administration errors, and environmental safety concerns such as kitchen sanitation and nurse staffing information posting. Complaint investigations substantiated neglect and safety issues, including a resident fall resulting in injury due to inadequate use of safety equipment and failure to follow physician orders for medication. Enforcement actions included denial of payment for new Medicare and Medicaid admissions due to actual harm-level deficiencies, but no license suspensions or fines were listed in the available reports. The facility appears to have made improvements over time, with repeated revisits confirming correction of previously cited deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
59 residents
Based on a August 2017 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 12, 2017
Visit Reason
The visit was a non-compliance revisit to the facility to determine if previously cited 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
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, resulting in denial of payment for new Medicare and Medicaid admissions and enforcement remedies without opportunity to correct before remedies are imposed.
Report Facts
Enforcement effective date: Aug 27, 2017
Compliance deadline: Feb 3, 2018
Hearing request deadline days: 60
IDR request deadline days: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact person for questions regarding the enforcement action and instructions in the letter |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 6
Aug 3, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation related to allegations of neglect and 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 preventing accidents, failed to post accurate nurse staffing data, failed to maintain sanitary food service conditions, and failed to maintain a safe and sanitary environment.
Complaint Details
The visit was complaint-related involving allegations of neglect and failure to prevent falls and injuries.
Severity Breakdown
SS=D: 2
SS=G: 1
SS=C: 1
SS=F: 1
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to thoroughly investigate and report an allegation of neglect involving a resident's injury from a wheelchair accident. | SS=D |
| Failed to review and revise the care plan with appropriate interventions for a cognitively impaired resident who sustained falls. | SS=D |
| Failed to provide adequate supervision and assistive devices to prevent accidents for residents, including improper transfer resulting in a fractured ankle. | SS=G |
| Failed to post daily nurse staffing schedule with actual staffing hours worked. | SS=C |
| Failed to store, prepare, distribute and serve food under sanitary conditions to prevent food borne illnesses. | SS=F |
| Failed to provide a safe, functional, sanitary, and comfortable environment, including failure to maintain kitchen floor sanitation. | SS=E |
Report Facts
Resident census: 59
Residents reviewed: 14
Residents reviewed for accidents: 4
Falls: 2
Fall assessment score: 9
Fall assessment score: 18
Certified Nurse Aides scheduled: 6
Certified Medication Aides scheduled: 3
Nurses scheduled: 2
Actual CNA hours worked: 45.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrative Staff | Stated facility's understanding of incident reporting process |
| Staff B | Administrative Nursing Staff | Provided information on resident falls and care plan revisions |
| Staff C | Licensed Nursing Staff | Provided information on resident mobility and interventions |
| Staff F | Direct Care Staff | Provided information on resident ambulation and fall risk |
| Staff J | Direct Care Staff | Witnessed wheelchair incident causing resident injury |
| Staff L | Direct Care Staff | Reported resident pain and swelling after wheelchair incident |
| Staff M | Direct Care Staff | Reported resident pain after wheelchair incident |
| Staff N | Dietary Staff | Confirmed kitchen sanitation observations |
| Staff O | Direct Care Staff | Described wheelchair foot pedal use and incident |
| Staff P | Administrative Staff | Discussed nurse staffing posting practices |
| Staff R | Physician Office Staff | Discussed timing of X-ray orders after resident injury |
Inspection Report
Life Safety
Deficiencies: 1
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. A plan of correction was required and enforcement remedies were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found at 'F' level | F |
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 report and mentioned in relation to enforcement and certification |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Plan of Correction
Deficiencies: 2
Jan 14, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to identified deficiencies during a prior inspection.
Findings
The Plan of Correction addresses deficiencies related to urinary catheter handling and dietary manager certification. Corrective actions include staff education, competency evaluations, and certification progress monitoring.
Severity Breakdown
D: 1
C: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Deficient practice in handling urinary catheters by nursing staff. | D |
| Dietary manager not yet certified but enrolled in an approved certification program. | C |
Report Facts
Corrective action completion date: Jan 14, 2016
Corrective action completion date: Jul 31, 2016
Inspection Report
Follow-Up
Deficiencies: 1
Jan 14, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the previously cited deficiency with regulation 483.25(d) was corrected as of the revisit date.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 483.25(d) |
Report Facts
Deficiencies corrected: 1
Inspection Report
Re-Inspection
Deficiencies: 1
Jan 14, 2016
Visit Reason
This revisit report documents the correction of deficiencies previously reported during a prior survey and confirms the date such corrective actions were accomplished.
Findings
The report indicates that the previously cited deficiency under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 01/14/2016.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) previously cited |
Inspection Report
Re-Inspection
Census: 57
Deficiencies: 1
Dec 16, 2015
Visit Reason
The inspection was a Health Resurvey to assess compliance with dietary services regulations.
Findings
The facility failed to retain the services of 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 the inspection; the registered dietitian visited every two weeks.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to employ a full-time certified dietary manager to oversee the dietary department. | Level C |
Report Facts
Census: 57
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 16, 2015
Visit Reason
This document is a Plan of Correction submitted in response to a deficiency report for Bethel ALF2 dated 12/16/2015.
Findings
No deficiencies were cited in the survey as indicated by the 'No deficiency survey' note.
Deficiencies (1)
| Description |
|---|
| No deficiency survey |
Inspection Report
Enforcement
Deficiencies: 1
Dec 16, 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 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.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency at a 'D' level, isolated, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Report Facts
Effective date of substantial compliance: Jan 14, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Named as contact and signatory related to enforcement and survey findings |
Inspection Report
Renewal
Deficiencies: 0
Dec 16, 2015
Visit Reason
The visit was a licensure resurvey of the facility to assess compliance for continued program participation.
Findings
The licensure resurvey resulted in a finding of no deficiency citations.
Inspection Report
Life Safety
Deficiencies: 1
Sep 16, 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 'D' level, isolated, with no harm but potential for more than minimal harm, and 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 was not achieved.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies found were 'D' level, isolated, with no harm but potential for more than minimal harm, not immediate jeopardy. | D |
Report Facts
Days to submit plan of correction: 10
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 and coordinated the survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 2
Oct 6, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report shows that deficiencies identified in prior surveys, specifically related to regulations 483.25(h) and 483.25(m)(2), were corrected as of the revisit date.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(m)(2) |
Report Facts
Deficiencies corrected: 2
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 12, 2014
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection, addressing concerns related to staffing and safety practices in the assisted living wing.
Findings
The facility immediately abated the concern by scheduling nursing staff for overnight shifts and implementing fire door modifications and regular staff rounds to ensure resident safety and timely response to needs.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have nursing staff scheduled for the 10 pm - 6 am shift and fire doors separating assisted living and skilled nursing wings not remaining open as required. | F |
Report Facts
Corrective action completion date: Oct 10, 2014
Scheduled rounds frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Krehbiel | CEO | Submitted the Plan of Correction |
Inspection Report
Enforcement
Deficiencies: 1
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.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an 'E' level deficiency, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and communicated the acceptance of the plan of correction. |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 2
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.
Findings
The facility failed to ensure that side rails on 17 resident beds met safety dimensional requirements to prevent entrapment hazards, and failed to follow physician orders for medication administration, resulting in a significant medication error involving a resident receiving blood pressure medication despite systolic readings below the ordered threshold.
Complaint Details
The visit was triggered by complaint investigation #74829. The complaint was substantiated as the facility was found to have safety and medication administration deficiencies.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Side rails on 17 resident beds contained open spaces greater than 4 and 3/4 inches, posing entrapment hazards. | Level D |
| Failure to follow physician orders for blood pressure medication administration, resulting in a significant medication error for resident #65. | Level D |
Report Facts
Resident beds with side rails having open spaces greater than 4 and 3/4 inches: 17
Census: 60
Residents reviewed for medication errors: 18
Resident #65 blood pressure readings: Multiple readings listed with systolic values ranging from 109 to 145
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff C | Interviewed regarding side rails and medication administration findings | |
| Direct care staff D | Reported medication administration error and blood pressure monitoring | |
| Consultant staff E | Reported on medication administration and blood pressure monitoring requirements | |
| Licensed nursing staff B | Confirmed medication administration errors and adherence to physician orders |
Inspection Report
Renewal
Census: 26
Deficiencies: 1
Sep 12, 2014
Visit Reason
The inspection was conducted as 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, as no staff were scheduled to be physically present during that time.
Deficiencies (1)
| Description |
|---|
| Failure to provide nursing staff attendance at all times for the 26 residents of assisted living, specifically no staff scheduled from 10:30 pm to 6:00 am. |
Report Facts
Census: 26
Inspection Report
Follow-Up
Deficiencies: 1
Sep 2, 2014
Visit Reason
This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the deficiency identified as F0323 related to regulation 483.25(h) was corrected by 08/01/2014. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency identified as F0323 related to regulation 483.25(h) |
Report Facts
Deficiency correction date: Aug 1, 2014
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 1, 2014
Visit Reason
This document is a plan of correction submitted in response to a complaint-related deficiency regarding the proper use and fitting of safety belts on bathing chairs.
Findings
The deficiency involved improper installation and fitting of safety belts on bathing chairs. The facility implemented corrective actions including staff counseling, in-service training, and ongoing monitoring by charge nurses to ensure compliance.
Complaint Details
This plan of correction is related to a complaint investigation identified by Event ID QGD311 and State ID N040001.
Deficiencies (1)
| Description |
|---|
| Improper installation and fitting of safety belts on bathing chairs |
Report Facts
Plan of Correction Completion Date: Aug 1, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for plan of correction assistance | |
| Leigh Peck | Executive Director | Submitted the plan of correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jul 30, 2014
Visit Reason
An abbreviated 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 to be at a 'G' level, resulting in a denial of payment for new Medicare admissions effective October 30, 2014, until substantial compliance is achieved.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found at a 'G' level | G |
Report Facts
Denial of payment effective date: Oct 30, 2014
Termination recommendation date: Jan 30, 2015
Civil Money Penalty minimum amount: 5000
IDR request deadline days: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact for questions concerning the instructions contained in the letter |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
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.
Findings
The facility failed to provide adequate supervision and use of safety belts on whirlpool tub lift chairs, resulting in a resident falling and sustaining three fractured vertebrae. Multiple staff confirmed that belts were often missing or not used, and training on belt use was inadequate or absent.
Complaint Details
Complaint investigation #76382 regarding unsafe environment and lack of proper use of safety belts during whirlpool tub transfers, substantiated by resident fall with injury.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure proper use of safety equipment (seat belts) during transfers in and out of the whirlpool bathtub, resulting in a resident fall and fractures. | SS=G |
Report Facts
Census: 60
Residents reviewed for accidents: 3
Residents using whirlpool bathtubs: 42
Fall Risk Assessment score: 17
Pain rating: 7
Date of resident fall: Jun 12, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct Care Staff D | Reported presence of new manual for belt use and demonstrated use of chair and belt | |
| Housekeeping Staff E | Reported belts were often not on lift chairs and stored elsewhere | |
| Maintenance Staff F | Reported belts had to be replaced due to disrepair and infection control concerns | |
| Licensed Nursing Staff C | Reported belt in north bathroom was frayed and not in use at time of fall | |
| Direct Care Staff H | Reported no belt present on night of fall and lack of training on belt use | |
| Administrative Nursing Staff B | Confirmed resident fall and lack of belt use; noted expectation of staff training on belt use | |
| Direct Care Staff I | Confirmed no belt use prior to fall and lack of training on belt use | |
| Administrative Staff A | Confirmed belts may not have always been on lift chairs and lack of awareness of non-use until after fall |
Inspection Report
Life Safety
Deficiencies: 1
Feb 10, 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 deficiencies to be 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 and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Isolated 'D' level deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy | D |
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
Follow-Up
Deficiencies: 4
Jun 22, 2013
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 revisit report confirms that all previously cited deficiencies identified by regulation numbers 483.25(h), 483.25(l), 483.35(d)(1)-(2), and 483.70(f) were corrected as of the revisit date.
Deficiencies (4)
| Description |
|---|
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.35(d)(1)-(2) |
| Deficiency related to regulation 483.70(f) |
Report Facts
Deficiencies corrected: 4
Previous survey date: May 23, 2013
Inspection Report
Re-Inspection
Deficiencies: 2
Jun 21, 2013
Visit Reason
This is a revisit report to verify correction of previously reported deficiencies at Bethel Health Care Centre.
Findings
The report documents that deficiencies previously cited under regulation numbers 28-39-254 and 28-39-256 were corrected as of 06/21/2013.
Deficiencies (2)
| Description |
|---|
| Deficiency identified by regulation number 28-39-254 |
| Deficiency identified by regulation number 28-39-256 |
Report Facts
Deficiencies corrected: 2
Inspection Report
Renewal
Census: 25
Deficiencies: 2
May 23, 2013
Visit Reason
The inspection was a Licensure Resurvey conducted 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, exposing residents to potential burn injuries.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure safe storage of hazardous chemicals accessible to cognitively impaired residents. | SS=E |
| Failure to monitor and maintain safe water temperatures in the dining room sink, exposing residents to potential burn injuries. | SS=E |
Report Facts
Residents affected: 13
Total residents: 25
Water temperature: 135.5
Water temperature: 129.9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| beauty shop staff C | Interviewed regarding chemical storage and use in beauty shop | |
| maintenance staff D | Checked and confirmed unsafe water temperature in dining room sink |
Inspection Report
Re-Inspection
Census: 59
Deficiencies: 4
May 15, 2013
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously identified deficiencies and overall facility regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to maintain safe water temperatures and secure kitchen access, failure to develop comprehensive care plans addressing black box warnings for medications for multiple residents, failure to prepare pureed foods properly conserving nutritive value and appearance, and failure to maintain a functioning resident call light system.
Severity Breakdown
SS=E: 3
SS=D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to test and maintain safe water temperatures in the North hall unsecured satellite kitchen, posing burn risks to residents. | SS=E |
| Failure to develop comprehensive care plans addressing black box warnings for medications for 10 of 31 sampled residents. | SS=E |
| Failure to prepare pureed foods in a manner that conserves nutritive value, flavor, and appearance for residents on pureed diets. | SS=D |
| Failure to develop and maintain a functioning call light system that promptly alerts staff to resident calls. | SS=E |
Report Facts
Facility census: 59
Residents sampled for care plan review: 31
Residents with deficient care plans: 10
Call light activation duration: 358
Water temperature measured: 133.8
Water temperature measured: 129
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff E | Interviewed regarding preparation of pureed foods and recipe adherence. | |
| Maintenance Supervisor F | Interviewed regarding water temperature monitoring and call light system functionality. | |
| Licensed Nurse B | Interviewed regarding medication administration system and black box warning alerts. | |
| Consultant Staff E | Provided facility with documentation on black box warnings and care planning. | |
| Direct Care Staff A, C | Interviewed regarding awareness of black box warnings and resident observation. | |
| Staff D | Interviewed regarding access to black box warning information and communication with CNAs. |
Inspection Report
Plan of Correction
Deficiencies: 2
N040001 POC 0E8R11
Visit Reason
This document is a Plan of Correction submitted by Bethel Health Care in response to deficiencies identified during a prior inspection.
Findings
The plan addresses two main deficiencies: bed rails with open spaces exceeding FDA recommendations and medication administration practices not following physician orders. Corrective actions include ordering space-filling devices for bed rails, staff education on medication administration, and ongoing quality assurance monitoring.
Severity Breakdown
E: 1
D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Bed rails have open spaces exceeding the FDA recommended 4.75 inches. | E |
| Medication administration did not follow physician ordered parameters. | D |
Report Facts
Corrective action completion date: Oct 6, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Peters | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 6
N040001 POC 87SY11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan outlines corrective actions taken or to be taken for multiple deficiencies related to resident care, incident reporting, fall prevention, mechanical lift use, nurse staffing information posting, and kitchen cleanliness and maintenance.
Severity Breakdown
D: 2
G: 1
C: 1
F: 1
E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Deficiency related to resident care plan revisions for pain treatment, foot wrapping, elevation, and placement to keep resident safe. | D |
| Deficiency related to fall prevention interventions including fall assessments, medication review, and incident reporting. | D |
| Deficiency related to mechanical lift use, resident transfers, and care plan revisions for residents with fractures and fall risks. | G |
| Deficiency related to nurse staffing information posting and training of nursing administrative assistant. | C |
| Deficiency related to kitchen cleanliness, including replacement and cleaning of various kitchen items and equipment. | F |
| Deficiency related to deep cleaning of kitchen floors and updated floor cleaning policy. | E |
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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Peters | Executive Director | Submitted the Plan of Correction to KDADS |
Document
Deficiencies: 0
N040001 POC 9W0011
Visit Reason
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Findings
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