Inspection Reports for
Bethel Health Care Center

The visit was complaint-related involving allegations of neglect and failure to prevent falls and injuries.

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.

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.

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.

The revisit confirmed that the previously cited deficiency with regulation 483.25(d) was corrected as of the revisit date.

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.

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.

No deficiencies were cited in the survey as indicated by the 'No deficiency survey' note.

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.

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.

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.

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.

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.

The visit was triggered by complaint investigation #74829. The complaint was substantiated as the facility was found to have safety and medication administration deficiencies.

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.

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.

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.

This plan of correction is related to a complaint investigation identified by Event ID QGD311 and State ID N040001.

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.

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.

Complaint investigation #76382 regarding unsafe environment and lack of proper use of safety belts during whirlpool tub transfers, substantiated by resident fall with injury.

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.

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.

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.

The report documents that deficiencies previously cited under regulation numbers 28-39-254 and 28-39-256 were corrected as of 06/21/2013.

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.

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.

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.

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.