Inspection Report Summary
The most recent inspection on March 31, 2025, found the facility in compliance with all regulations and no new deficiencies. Earlier inspections showed a pattern of deficiencies related mainly to care planning, wound and pressure ulcer management, accident hazard prevention, psychotropic medication monitoring, and infection control. A notable substantiated complaint investigation in August 2023 cited a failure to secure facility vehicles, which led to a resident elopement incident; the facility responded with staff education and safety measures. Prior reports did not list fines, immediate jeopardy findings, or license actions in the available records. The facility has demonstrated improvement over time by correcting all cited deficiencies from previous inspections.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
28% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
50 residents
Based on a January 2025 inspection.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 31, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-01-16.
Findings
All previously cited deficiencies have been corrected as of the compliance date 2025-02-28, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 7
Jan 16, 2025
Visit Reason
Health Recertification Survey conducted to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in developing and implementing person-centered comprehensive care plans, timely care plan revisions, treatment and prevention of pressure ulcers, accident hazard prevention, psychotropic medication management, infection prevention and control, and antibiotic stewardship.
Severity Breakdown
SS=D: 5
SS=E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to develop and implement person-centered comprehensive care plans for residents related to psychotropic medication use, oxygen and nebulized medication use, and pressure ulcer care. | SS=D |
| Failed to revise care plans timely after falls, pressure ulcers, and psychotropic medication changes for multiple residents. | SS=E |
| Failed to provide necessary treatment and ongoing assessment for a stage three facility acquired pressure ulcer. | SS=D |
| Failed to ensure a safe environment free from accident hazards and adequate supervision to prevent accidents, including unsecured medications and lack of fall interventions. | SS=E |
| Failed to ensure PRN psychotropic medication had required 14 day stop date or clinical rationale for continued use beyond 14 days. | SS=D |
| Failed to ensure staff followed appropriate hand hygiene during wound care to prevent infection. | SS=D |
| Failed to ensure an effective and ongoing antibiotic stewardship program to monitor antibiotic use and prevent resistance. | SS=D |
Report Facts
Census: 50
Residents reviewed: 14
PRN Xanax dose: 0.25
Pressure ulcer measurements: 6
BIMS scores: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Director of Nursing | Responsible for supervising care plan development and infection control |
| Administrative Nurse C | Infection Preventionist | Responsible for infection control and antibiotic stewardship |
| Licensed Nurse X | Licensed Nurse | Provided information on care plan updates and wound care |
| Certified Nurse Aide P | Certified Nurse Aide | Provided information on skin care reporting |
| Certified Nurse Aide U | Certified Nurse Aide | Provided information on skin care reporting |
| Licensed Nurse J | Licensed Nurse | Observed failing to perform proper hand hygiene during wound care |
| Licensed Nurse H | Licensed Nurse | Observed failing to perform proper hand hygiene during wound care |
| Certified Medication Aide M | Certified Medication Aide | Reported medication storage practices in resident rooms |
| Certified Nursing Assistant O | Certified Nursing Assistant | Observed failing to perform proper hand hygiene during wound care |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 19, 2023
Visit Reason
An offsite revisit survey was conducted on 10/19/2023 for all previous deficiencies cited on 08/16/2023.
Findings
All deficiencies have been corrected as of the compliance date of 09/01/2023, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiency citation date: Aug 16, 2023
Compliance date: Sep 1, 2023
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Aug 16, 2023
Visit Reason
The inspection was conducted as a complaint investigation (#KS00182093) regarding a resident elopement incident involving a facility owned vehicle.
Findings
The facility failed to ensure a safe environment for a resident with moderately impaired cognition by not removing keys from a facility owned golf cart, which allowed the resident to leave the facility and operate the vehicle on public roadways. The facility lacked adequate interventions and signage to prevent such incidents and did not have physician orders restricting unescorted outdoor mobility.
Complaint Details
The complaint investigation found that Resident 1, with moderately impaired cognition and a history of falls, eloped from the facility on 08/10/23 by driving a facility owned golf cart off the property without staff knowledge. Staff were not immediately notified, and the resident was found three blocks away. The facility's response included staff education and removal of keys from all facility vehicles.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to remove keys from a facility owned vehicle/golf cart, allowing a resident to elope and operate the vehicle on public roadways. | SS=D |
Report Facts
Resident census: 55
BIMS score: 11
Date of elopement incident: Aug 10, 2023
Temperature: 89
Wind speed: 16
Distance from facility: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff E | Found Resident 1 driving the golf cart approximately three blocks from the facility and followed him back | |
| Certified Nurse Aide F | CNA | Accompanied Resident 1 back to the facility in the golf cart after elopement |
| Physical Therapy Staff C | Observed Resident 1 driving the golf cart off the facility property and notified the facility | |
| Certified Nurse Aide D | CNA | Observed Resident 1 near the unattended golf cart prior to elopement |
| Certified Nurse Aide G | CNA | On duty during the incident but was not notified until after Resident 1 returned |
| Certified Nurse Aide H | CNA | Described staff procedures for locating missing residents |
| Administrative Nurse B | Administrative Nurse | Described facility expectations and interventions following the elopement |
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 16, 2023
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection at Bethel Home, specifically addressing an incident involving resident elopement and related safety concerns.
Findings
The plan outlines corrective actions including staff education on elopement procedures, removal and secure storage of vehicle keys, implementation of wander guards, resident safety evaluations, and ongoing audits to prevent recurrence of elopement incidents.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly secure facility vehicles and prevent resident elopement. | D |
Report Facts
Completion date for corrective actions: Sep 1, 2023
Frequency of wander screens: 90
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 13, 2023
Visit Reason
A revisit survey was conducted on 03/13/2023 for all previous deficiencies cited on 02/01/2023.
Findings
All deficiencies have been corrected as of the compliance date of 03/04/2023, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Deficiency correction compliance date: Mar 4, 2023
Inspection Report
Plan of Correction
Deficiencies: 5
Feb 1, 2023
Visit Reason
This document is a Plan of Correction submitted by Bethel Home in response to deficiencies cited in a prior inspection report dated 2023-02-01, addressing wound documentation and incident investigation failures.
Findings
The Plan of Correction outlines multiple corrective actions including staff education on wound documentation, audits of skin assessments and care plans, implementation of risk management and quality assurance teams, and ongoing monitoring to ensure compliance with wound care protocols.
Severity Breakdown
D: 3
G: 1
F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to properly report and document wounds and complete incident investigations regarding wounds. | D |
| Inadequate care plan documentation and interventions for residents at risk for skin issues. | D |
| Failure to provide adequate nurse education on wound identification, classification, treatment, and follow-up. | D |
| Inadequate staging and documentation of wounds, inconsistent charting, and failure to implement weekly wound measurements and assessments. | G |
| Failure to complete nurse competencies and audits related to wound care and documentation. | F |
Report Facts
Completion date for corrective actions: Mar 4, 2023
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 6
Feb 1, 2023
Visit Reason
Annual health resurvey conducted to assess compliance with regulatory requirements related to resident care, skin integrity, and wound management.
Findings
The facility failed to properly investigate injuries of unknown origin, develop baseline care plans for residents with wounds, identify and document skin issues including pressure injuries and skin tears, and maintain a system for consistent tracking, monitoring, and measuring of wounds. Licensed nurse competencies regarding wound care were inadequate, and the QAPI program failed to implement timely corrective actions to address these deficiencies.
Severity Breakdown
SS=D: 3
SS=G: 1
SS=F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to initiate an investigation and implement interventions when Resident 51 sustained bruising and a skin tear with no documentation or follow-up. | SS=D |
| Failed to develop and implement a baseline care plan for Resident 54 with a deep tissue injury to the left heel, lacking documentation and interventions. | SS=D |
| Failed to identify, document, track, and measure skin issues for Resident 23 including multiple skin tears, bruising, and surgical wound with no measurements or follow-up. | SS=D |
| Failed to establish and maintain a system to identify, track, and measure wounds for Resident 51 with multiple pressure injuries and Resident 54 with a deep tissue injury, including lack of documentation and follow-up. | SS=G |
| Failed to ensure licensed nurse competency in monitoring, measuring, identifying skin issues and pressure injuries, resulting in inconsistent wound care and documentation. | SS=F |
| Failed to ensure the QAPI program developed and implemented timely corrective actions to address quality deficiencies identified in the annual health resurvey. | SS=F |
Report Facts
Facility census: 54
Resident 51 census: 54
Resident 23 BIMS score: 13
Resident 54 BIMS score: 15
Resident 51 BIMS score: 2
Resident 41 BIMS score: 15
Resident 41 pressure ulcer size: 0.2
Resident 54 pressure injury size: 5
Resident 23 skin tear size: 6.5
Resident 9 right great toe wound size: 1
Resident 9 right great toe wound size: 0.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Interviewed regarding wound tracking system, expectations for wound documentation, and QAPI involvement |
| Licensed Nurse H | Licensed Nurse | Interviewed regarding wound documentation and care for Resident 51 and Resident 54 |
| Licensed Nurse K | Licensed Nurse | Interviewed regarding wound care and communication with CNAs |
| Administrative Nurse E | Administrative Nurse | Interviewed regarding wound tracking, MDS assessments, and QAPI reporting |
| Administrative Nurse C | Administrative Nurse | QAPI officer interviewed regarding QAPI process and corrective actions |
| Certified Nurse Aide N | Certified Nurse Aide | Interviewed regarding reporting skin concerns |
| Certified Nurse Aide O | Certified Nurse Aide | Interviewed regarding reporting skin concerns |
| Certified Nurse Aide Q | Certified Nurse Aide | Interviewed regarding skin observations and communication with nurses |
| Licensed Nurse G | Licensed Nurse | Interviewed regarding wound care and physician orders for Resident 54 |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 16, 2021
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 03/24/21.
Findings
All deficiencies cited in the previous inspection have been corrected as of 04/09/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 52
Deficiencies: 1
Mar 24, 2021
Visit Reason
The inspection was a Health Resurvey to assess compliance with regulations related to medication monitoring, specifically focusing on the adequacy of monitoring insulin for residents.
Findings
The facility failed to ensure adequate monitoring of insulin for Resident 45, as staff did not report out-of-parameter blood glucose readings to the physician as required by physician orders and facility policy.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure adequate monitoring of insulin when staff failed to report out of parameter blood glucose levels for Resident 45. | SS=D |
Report Facts
Census: 52
Out of parameter blood glucose readings: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide (CMA) C | Reported obtaining blood glucose readings but did not know parameters for Resident 45 | |
| Licensed Nurse D | Responsible for reporting out of parameter blood glucose readings to the physician | |
| Administrative Nurse A | Expected nurses to follow physician orders and notify physician of out of parameter blood glucose readings |
Inspection Report
Routine
Deficiencies: 0
Nov 16, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Kansas Department for Aging and Disability Services (KDADS) to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with Centers for Medicare & Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Follow-Up
Deficiencies: 0
Sep 16, 2019
Visit Reason
An offsite revisit survey was conducted on 09/16/19 to verify correction of all previous deficiencies cited on 08/08/19.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 08/20/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies corrected: All deficiencies cited on 08/08/19 were corrected by 08/20/19
Inspection Report
Plan of Correction
Deficiencies: 4
Aug 8, 2019
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in the CMS Health Survey Statement of Deficiencies dated August 8, 2019, for Bethel Home RS.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including updating care plans for residents, monitoring vital signs including oxygen saturation, and monitoring specific targeted behaviors for residents on psychotropic medications. Policies were updated and staff education was planned to ensure compliance and sustainability.
Severity Breakdown
D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Resident #33's care plan was updated to include comfort care status and audits will be conducted to identify missing orders or interventions. | D |
| Resident #46's vital signs monitoring was enhanced to include oxygen saturation twice weekly, with audits to identify residents at risk for respiratory distress. | D |
| Orders were added to monitor specific targeted behaviors for residents R20, R21, and R51 taking psychotropic medications, with updated policies and staff education. | D |
| Additional monitoring and education for night charge nurses on chart checks and order entry related to psychotropic medications. | D |
Report Facts
Deficiencies cited: 4
Plan of Correction completion date: Aug 20, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Koehn | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 4
Aug 8, 2019
Visit Reason
The inspection was a Health Resurvey to assess compliance with regulatory requirements for Bethel Home nursing facility.
Findings
The facility was found deficient in timely revision of comprehensive care plans, ensuring necessary respiratory care, and proper drug regimen review including monitoring of psychotropic medications. Specific failures included lack of timely care plan updates for comfort care, inadequate respiratory monitoring for a resident on opioids, and failure of the consultant pharmacist and staff to monitor specific targeted behaviors related to psychoactive medications for multiple residents.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure timely revision of person-centered comprehensive care plan for Resident 33 when comfort care was required. | SS=D |
| Failure to ensure necessary respiratory care and monitoring for Resident 46, including lack of physician notification for low oxygen saturation levels. | SS=D |
| Failure to ensure consultant pharmacist identified lack of specific targeted behavior monitoring for Residents 21, 51, and 20 related to psychoactive medications. | SS=D |
| Failure to ensure residents did not receive unnecessary psychotropic medications due to lack of monitoring specific targeted behaviors for Residents 21, 51, and 20. | SS=D |
Report Facts
Facility census: 54
Residents reviewed for unnecessary medications: 5
BIMS score: 5
BIMS score: 8
Oxygen saturation levels: 82
Oxygen saturation levels: 86
Medication doses: 0.5
Medication doses: 0.25
Medication doses: 10
Medication doses: 0.5
Medication doses: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Consultant Pharmacist J | Consultant Pharmacist | Interviewed regarding failure to identify lack of behavior monitoring for residents on psychoactive medications |
| Administrative Nurse B | Administrative Nurse | Provided information on care plan updates and behavior monitoring policies |
| Administrative Nurse A | Administrative Nurse | Provided information on care plan updates and behavior monitoring policies |
| Licensed Nurse D | Licensed Nurse | Interviewed regarding care plan updates and respiratory monitoring for Resident 33 and 46 |
| Certified Nurse Aide E | Certified Nurse Aide | Interviewed regarding care plan use and resident care |
| Licensed Nurse C | Licensed Nurse | Interviewed regarding respiratory monitoring and physician notification |
| Certified Nurse Aide G | Certified Nurse Aide | Interviewed regarding resident behaviors and staff charting |
| Licensed Nurse H | Licensed Nurse | Interviewed regarding resident behaviors and staff charting |
| Licensed Nurse I | Licensed Nurse | Interviewed regarding resident behaviors and medication effects |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 5, 2018
Visit Reason
The document is a Plan of Correction submitted in response to a health survey of the facility.
Findings
The health survey 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
Annual Inspection
Deficiencies: 0
Jun 5, 2018
Visit Reason
The health survey was conducted to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in no deficiency citations, indicating full compliance with the applicable long term care facility regulations.
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 23, 2016
Visit Reason
The health survey was conducted to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in a finding of no deficiency citations with respect to the applicable regulations.
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 23, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for Bethel Home Montezuma dated 02/23/2016.
Findings
No deficiencies were cited in the related inspection report dated 02/23/2016.
Deficiencies (1)
| Description |
|---|
| No deficiencies were cited. |
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 6, 2014
Visit Reason
The health survey was conducted as a regulatory inspection to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The survey resulted in no deficiency citations, indicating full compliance with the applicable long term care facility regulations.
Inspection Report
Plan of Correction
Census: 55
Deficiencies: 1
Jul 25, 2013
Visit Reason
The inspection was conducted to evaluate compliance with nursing facility support system requirements, specifically the presence and functionality of emergency call light systems.
Findings
The facility failed to have an enunciator panel or monitor screen for the call light system at the Cottonwood Hall nurses work station, which housed 22 of the 55 residents. The policy review also showed the system did not address enunciator panels in all nurses work stations.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have an enunciator panel or monitor screen for the call light system at the Cottonwood Hall nurses work station. | SS=E |
Report Facts
Census: 55
Residents in Cottonwood Hall: 22
Inspection Report
Follow-Up
Deficiencies: 4
Jun 7, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies identified in the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that all cited deficiencies under regulations 483.20(b)(1), 483.25(h), 483.25(l), and 483.60(c) were corrected as of the revisit date.
Deficiencies (4)
| Description |
|---|
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.60(c) |
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 4
May 25, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey and to outline corrective actions and ongoing compliance measures.
Findings
The facility identified deficiencies related to resident assessments, fall risk management, medication monitoring, and documentation. The Plan of Correction details specific actions including policy development, staff education, audits, and monitoring to ensure compliance and resident safety.
Severity Breakdown
D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to conduct initial and periodic comprehensive, accurate, standardized assessments of each resident's functional capacity. | D |
| Inadequate fall risk assessment and management, including failure to complete fall risk assessments promptly and develop appropriate care plans. | D |
| Insufficient monitoring and documentation of bowel movements and blood pressure, and failure to audit drug regimens for contraindications. | D |
| Lack of comprehensive review and documentation of incidents including falls and vital sign data during pharmacy consultant visits. | D |
Report Facts
Date of policy implementation: May 10, 2012
Date of staff in-service: May 23, 2012
Date Metoprolol stopped: May 11, 2012
Audit frequency: 4
Next pharmacy consultant visit: 201206
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brett Nichols | Operatings Manager | Submitted the Plan of Correction to KDADS |
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 4
May 8, 2012
Visit Reason
The inspection was a health facility resurvey to assess compliance with regulatory requirements, including comprehensive assessments, accident prevention, and drug regimen monitoring.
Findings
The facility failed to conduct comprehensive assessments for 3 sampled residents, ensure adequate supervision to prevent accidents for 1 resident, and maintain drug regimens free from unnecessary medications for 2 residents. Additionally, the pharmacy consultant failed to report irregularities related to low blood pressure for one resident.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to conduct periodic comprehensive, accurate assessments for 3 of 10 sampled residents (#19, #36, #38). | SS=D |
| Failed to ensure adequate supervision and assistance to prevent accidents for resident #19. | SS=D |
| Failed to ensure drug regimen free from unnecessary drugs for 2 residents (#42 and #19) due to inadequate monitoring and documentation. | SS=D |
| Pharmacy consultant failed to report irregularities including low blood pressure readings to attending physician and director of nursing for resident #19. | SS=D |
Report Facts
Residents sampled: 10
Census: 54
Medication dosage: 100
Medication dosage: 25
Medication dosage: 20
Blood pressure low readings: 2
Days without bowel movement documentation: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse B | Administrative Nurse | Confirmed failures in monitoring and documentation related to residents #19 and #42. |
| Licensed nurse C | Licensed Nurse | Confirmed resident #19's decline and lack of timely assessments and interventions. |
| Consultant staff F | Pharmacy Consultant | Confirmed failure to review vital signs and report low blood pressure irregularities for resident #19. |
Inspection Report
Plan of Correction
Deficiencies: 1
N035001 POC UV5811
Visit Reason
This document is the facility's Plan of Correction responding to deficiencies cited in the CMS Health Resurvey 'Statement of Deficiencies' related to blood sugar monitoring and notification.
Findings
The Plan of Correction addresses the deficiency related to out-of-parameter blood sugar monitoring and notification protocols, including immediate corrective actions, staff re-education, policy revisions, and ongoing monitoring plans.
Deficiencies (1)
| Description |
|---|
| Deficiency related to blood sugar monitoring and notification (Tag #F757) |
Report Facts
Plan of Correction completion date: Apr 9, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Koehn | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 4
N035001 POC 6LKL11
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 of Correction indicates that no corrective action was required for the listed deficiencies (F0000, F371-F, F431-E, S1166-E) as noted by 'No POC required' with completion dates of 07/25/2013.
Deficiencies (4)
| Description |
|---|
| Deficiency F0000 |
| Deficiency F371-F |
| Deficiency F431-E |
| Deficiency S1166-E |
Inspection Report
Plan of Correction
Deficiencies: 6
N035001 POC JOUI11
Visit Reason
This document is a Plan of Correction submitted by Bethel Home in response to a Statement of Deficiencies identified during a regulatory inspection.
Findings
The Plan of Correction outlines multiple corrective actions including discharge planning improvements, nurse education on care plan interventions, wound care and pressure injury management, psychotropic medication monitoring, hand hygiene protocols, and infection tracking enhancements.
Severity Breakdown
D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Discharge planning will be completed according to RAI guidelines with interdisciplinary team involvement. | D |
| Care plan interventions for pressure injuries and falls will be improved through education and audits. | D |
| In-service training on proper staging, documentation, and weekly wound care orders for pressure injuries. | D |
| Audit and review of PRN psychotropic medication use with new protocols for monitoring and documentation. | D |
| Hand hygiene education and check-offs for all direct care staff. | D |
| Updated infection tracking process and education on culture and sensitivity documentation and infection prevention. | D |
Report Facts
Completion date: Feb 21, 2025
Completion date: Feb 28, 2025
Next QAPI meeting: Mar 4, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Brian Koehn | Administrator | Submitted the Plan of Correction |
| Jessica Patterson | Added the Plan of Correction | |
| Lori Mouak | Modified the Plan of Correction |
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