Deficiencies (last 10 years)
Deficiencies (over 10 years)
7.1 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
18% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
89% occupied
Based on a January 2025 inspection.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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 deficiencies cited in the prior inspection have been corrected as of the compliance date 2025-02-28. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 7
Date: Jan 16, 2025
Visit Reason
The visit was a Health Recertification Survey to assess compliance with federal regulations for nursing facilities.
Findings
The facility had multiple deficiencies including failure to develop and implement comprehensive person-centered care plans, failure to revise care plans timely after falls and pressure ulcers, inadequate infection control practices, unsafe medication storage, and ineffective antibiotic stewardship.
Deficiencies (7)
F656: The facility 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.
F657: The facility failed to revise care plans timely after falls, pressure ulcers, and psychotropic medication changes for several residents.
F686: The facility failed to perform ongoing assessment and monitoring of a stage three facility-acquired pressure ulcer for a resident.
F689: The facility failed to ensure a safe environment free from accident hazards including unsecured medications and inadequate fall prevention interventions.
F758: The facility failed to ensure a 14-day stop date or clinical rationale for continued use beyond 14 days for a resident's PRN psychotropic medication.
F880: The facility failed to ensure staff followed appropriate hand hygiene during wound care, risking infection transmission.
F881: The facility failed to ensure an effective antibiotic stewardship program to monitor antibiotic use and prevent resistance.
Report Facts
Resident census: 50
Residents sampled: 14
Loose stools: 56
Total stools: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Director of Nursing | Named in relation to care plan development and oversight |
| Administrative Nurse C | Infection Preventionist | Named in relation to infection control and antibiotic stewardship |
| Licensed Nurse X | Licensed Nurse | Named in relation to wound care and care plan updates |
| Certified Nurse Aide P | Certified Nurse Aide | Named in relation to skin care and fall interventions |
Inspection Report
Routine
Census: 50
Deficiencies: 7
Date: Jan 16, 2025
Visit Reason
Routine inspection of Bethel Home nursing facility to assess compliance with care planning, fall prevention, pressure ulcer care, medication management, infection control, and antibiotic stewardship.
Findings
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, including timely updates for pressure ulcers, falls, and psychotropic medication changes. Unsafe medication storage and incomplete fall interventions were noted. Infection control practices were inadequate during wound care, and antibiotic stewardship monitoring was ineffective.
Deficiencies (7)
F0656: The facility 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.
F0657: The facility failed to revise care plans timely for falls, pressure ulcers, and psychotropic medication changes for multiple residents.
F0686: The facility failed to perform ongoing assessments of a stage three facility-acquired pressure ulcer for Resident 2.
F0689: The facility failed to ensure a safe environment free from accident hazards, including unsecured medications and lack of fall prevention interventions for several residents.
F0758: The facility failed to ensure a 14-day stop date or physician evaluation for continued use beyond 14 days for Resident 46's PRN psychotropic medication Xanax.
F0880: The facility failed to ensure staff followed appropriate hand hygiene during wound care for Residents 2 and 21, risking infection spread.
F0881: The facility failed to implement an effective antibiotic stewardship program to monitor appropriate antibiotic use and prevent resistance.
Report Facts
Resident census: 50
Residents sampled: 14
PRN Xanax doses: 2
Pressure ulcer measurements: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Director of Nursing | Named in relation to care plan development and oversight |
| Administrative Nurse C | Infection Preventionist | Named in relation to infection control and antibiotic stewardship |
| Licensed Nurse X | Licensed Nurse | Named in relation to care plan updates and infection control observations |
| Certified Nurse Aide P | CNA | Named in relation to care plan and fall incident reporting |
| Certified Medication Aide M | CMA | Named in relation to medication storage and care plan knowledge |
Inspection Report
Plan of Correction
Deficiencies: 19
Date: Jan 16, 2025
Visit Reason
This document is a Plan of Correction submitted by Bethel Home RS in response to deficiencies cited during an inspection conducted on January 16, 2025.
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 compliance, and infection tracking enhancements.
Deficiencies (19)
F656-D: Discharge planning will be completed according to RAI guidelines with interdisciplinary team meetings and documentation of resident discharge goals.
F656-D: Licensed nurses will receive in-service education on proper care plan interventions for new or worsening pressure injuries or falls.
F656-D: Nurse education will cover immediate addition of physician’s orders to care plans, including oxygen, nebulizer treatments, psychotropic meds, falls, and wounds.
F656-D: Designated wound and fall nurses will audit monthly for appropriate interventions and provide individual education as needed.
F656-D: Monthly QAPI meetings will review falls and wounds, and education on proper oxygen tubing storage will be provided to direct care staff.
F656-D: Care plan audits will check accuracy and update interventions, including for residents on oxygen and those with skin issues.
F656-D: Licensed staff will be educated on completing new and monthly Braden’s assessments to identify pressure injuries.
F657-E: Care plan audits will check for accuracy and appropriate interventions for falls and pressure injuries.
F657-E: Education will be provided on proper care plan interventions for pressure injuries and falls.
F657-E: Nurse education on immediate addition of physician’s orders to care plans will be provided with posted information sheets.
F686-D: In-service training for licensed nurses on proper staging, documentation, and weekly measurement of wounds will be completed.
F686-D: Audits will ensure procedures for residents with pressure injuries are in place and weekly wound care orders are completed.
F686-D: Nurse competency and wound care procedures will be reviewed, emphasizing proper procedures and wound care orders.
F686-D: Licensed staff will be educated on completing Braden’s assessments monthly and identifying residents at risk for pressure injuries.
F758-D: Audits will review current PRN psychotropic medication use for need and rationale, with new protocols for monitoring and documentation.
F758-D: PCP will be notified of new procedures, and education on care plan interventions for psychotropic medications will be provided.
F880-D: All direct care staff will perform hand hygiene check-offs, and education on hand hygiene with wound care and peri-care will be provided.
F881-D: Infection tracking will be updated to include organism information, with education on documentation, notification, and contact precautions.
F881-D: Education will be provided on bowel movement charting and notification protocols, with information shared with the medical director and QAPI team.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 19, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of 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.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Aug 16, 2023
Visit Reason
The inspection was conducted as a complaint investigation (#KS00182093) related to a resident elopement incident involving a facility-owned golf cart.
Complaint Details
The complaint investigation was triggered by an incident where Resident 1 eloped from the facility on 08/10/23 by driving a facility-owned golf cart without staff knowledge. The resident had moderately impaired cognition and was identified as an elopement risk after the incident. Staff were not adequately trained or prepared to prevent or respond to the elopement.
Findings
The facility failed to ensure a safe environment for a resident with moderately impaired cognition by not removing keys from a facility-owned vehicle, which allowed the resident to leave the facility and operate the golf cart on public roadways. The care plan and physician's orders lacked specific interventions for outside facility supervision, and staff training on elopement procedures was incomplete.
Deficiencies (1)
CFR 483.25(d) Accidents. The facility failed to ensure the resident environment was free of accident hazards by not removing keys from a facility-owned golf cart, allowing a resident to elope and operate the vehicle unsupervised on public roads.
Report Facts
Resident census: 55
BIMS score: 11
Temperature: 89
Wind speed: 16
Distance from facility: 3
Course duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff E | Found Resident 1 driving the golf cart and followed him back to the facility. | |
| Certified Nurse Aide F | CNA | Accompanied Resident 1 back to the facility in the golf cart and reported on the incident. |
| Physical Therapy Staff C | Observed Resident 1 driving the golf cart off the property and notified the facility. | |
| Certified Nurse Aide D | CNA | Witnessed Resident 1 near the unattended golf cart before the 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 expectations for responding to resident elopement. |
| Administrative Nurse B | Administrative Nurse | Described facility expectations for elopement response and staff training. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 16, 2023
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection at Bethel Home.
Findings
The plan addresses an incident involving resident elopement risk and outlines corrective actions including staff education, key control procedures, resident safety evaluations, and ongoing monitoring to prevent recurrence.
Deficiencies (1)
F689-D: Resident involved in an incident was educated on proper procedures for leaving the facility and using equipment. Staff were trained on key control and elopement policies, with audits and safety measures implemented to prevent recurrence.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 13, 2023
Visit Reason
A revisit survey was conducted to verify correction of 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.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Feb 1, 2023
Visit Reason
This document is a Plan of Correction submitted by Bethel Home in response to deficiencies cited during a prior inspection on 2023-02-01.
Findings
The plan addresses failures in wound documentation, reporting, and investigation. It outlines corrective actions including staff education, audits, risk management team formation, and ongoing monitoring to ensure compliance with wound care protocols.
Deficiencies (6)
Tag F610-D: Staff failed to properly report and document wounds and complete incident investigations related to wound R51. Immediate education and audits will be conducted to prevent recurrence.
Tag F655-D: Care plans for resident R54 were inadequate for skin issues. Reviews and audits will ensure proper documentation and interventions are in place.
Tag F684-D: Nurse education on identification, classification, treatment, and follow-up of skin tears and bruising will be provided. Audits will ensure no unidentified skin issues remain.
Tag F686-G: In-service training will be completed for licensed nurses on wound staging, documentation, and consistent charting. Weekly wound measurements and assessments will be implemented.
Tag F726-F: Nurse competencies including skin integrity and wound assessment will be completed. Weekly audits of nursing notes and wound assessments will be conducted.
Tag F867-F: A QAPI-PIP team was formed to address deficiencies cited in the annual health resurvey. Staff involved in wound reporting failures were re-educated and compliance will be monitored weekly.
Report Facts
Plan of Correction completion date: Mar 4, 2023
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 6
Date: Feb 1, 2023
Visit Reason
Annual health resurvey of Bethel Home to assess compliance with regulatory requirements related to resident care, skin integrity, wound management, and nursing competencies.
Findings
The facility failed to investigate injuries of unknown origin, develop baseline care plans for residents with wounds, identify and track skin issues including pressure injuries and skin tears, and ensure licensed nurse competencies in wound care. The QAPI program also failed to implement timely corrective actions to address these deficiencies.
Deficiencies (6)
F610: The facility failed to investigate bruising and a skin tear on Resident 51 and did not implement interventions to prevent further injury.
F655: The facility failed to develop and implement a baseline care plan for Resident 54's deep tissue injury to the left heel, lacking documentation and interventions.
F684: The facility failed to identify, document, and track skin tears, bruising, and surgical wound on Resident 23, lacking measurements and follow-up.
F686: The facility failed to establish and maintain a system to identify, track, and measure wounds for Residents 51, 54, 9, and 41, resulting in inadequate documentation and risk of worsening injuries.
F726: The facility failed to ensure licensed nurses demonstrated competency in wound care, including monitoring, measuring, and identifying skin issues and pressure injuries.
F867: The facility failed to ensure the QAPI program developed and implemented timely corrective actions to address quality deficiencies identified in the annual health resurvey.
Report Facts
Facility census: 54
Resident 51 BIMS score: 2
Resident 54 BIMS score: 15
Resident 23 BIMS score: 13
Resident 41 BIMS score: 15
Resident 51 pressure injury stage I: 1
Resident 51 pressure injury stage II: 1
Resident 54 unstageable pressure injury: 1
Resident 41 stage II pressure ulcers: 2
Resident 23 skin tear size: 6.5
Resident 9 right great toe wound size: 0.6
Resident 9 right great toe wound size post debridement: 1
Resident 41 left buttock wound size: 7
Resident 41 left heel wound size: 1.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Interviewed regarding wound tracking, QAPI, and nursing competencies |
| Administrative Nurse E | Administrative Nurse | Interviewed regarding wound tracking, QAPI, and nursing competencies |
| Administrative Nurse C | Administrative Nurse | QAPI officer interviewed about QAPI program and corrective actions |
| Licensed Nurse H | Licensed Nurse | Interviewed regarding wound care and resident assessments |
| Licensed Nurse K | Licensed Nurse | Interviewed regarding wound care and resident assessments |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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 have been corrected as of the compliance date of 04/09/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 6, 2021
Visit Reason
This document is a Plan of Correction submitted by Bethel Home in response to deficiencies cited during the CMS Health Resurvey.
Findings
The Plan of Correction addresses issues related to out-of-parameter blood sugar monitoring and notification protocols for residents with diabetes. Bethel Home outlines corrective actions, staff re-education, policy revisions, and ongoing monitoring to prevent recurrence.
Deficiencies (1)
Tag #F757: Bethel Home failed to properly monitor and notify the physician of out-of-parameter blood sugar levels for resident #45. Corrective actions include new physician orders, staff re-education, and policy revisions.
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: Mar 24, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure adequate monitoring of insulin for Resident 45, specifically the failure to report out of parameter blood glucose levels as ordered by the physician.
Complaint Details
The complaint investigation found that the facility did not notify the physician for Resident 45's out of parameter blood glucose readings despite multiple documented elevated readings from January through March 2021. The facility's policy required timely notification, which was not followed.
Findings
The facility failed to notify the physician of Resident 45's out of parameter blood glucose readings as required by physician orders. Multiple elevated blood glucose readings were documented without corresponding physician notification, indicating inadequate monitoring of insulin administration.
Deficiencies (1)
F 0757: The facility failed to ensure each resident’s drug regimen was free from unnecessary drugs by not reporting out of parameter blood glucose levels for Resident 45 as ordered by the physician.
Report Facts
Residents in census: 52
Out of parameter elevated blood glucose readings: 6
Out of parameter elevated blood glucose readings: 8
Out of parameter elevated blood glucose readings: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide (CMA) | Reported obtaining blood glucose readings and reporting to nurse but unaware of parameters | |
| Licensed Nurse (LN) | Responsible for reporting out of parameter blood glucose readings to physician | |
| Administrative Nurse A | Expected nurse to follow physician orders and notify physician of out of parameter readings |
Inspection Report
Re-Inspection
Census: 52
Deficiencies: 1
Date: Mar 24, 2021
Visit Reason
The inspection was a health resurvey to assess compliance with medication monitoring requirements, specifically related to unnecessary drug use and insulin monitoring.
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 ordered. Multiple elevated blood glucose readings were documented without corresponding physician notification.
Deficiencies (1)
F 757 Drug Regimen is Free from Unnecessary Drugs. The facility failed to notify the physician of out-of-parameter blood glucose readings for Resident 45, resulting in inadequate monitoring of insulin therapy.
Report Facts
Resident 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 or physician notification requirements | |
| Licensed Nurse D | Responsible for reporting out-of-parameter blood glucose readings to the physician | |
| Administrative Nurse A | Expected nursing staff to follow physician orders and notify physician of out-of-parameter blood glucose readings |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: 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).
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
Re-Inspection
Deficiencies: 0
Date: Sep 16, 2019
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-08-08.
Findings
All deficiencies have been corrected as of the compliance date of 2019-08-20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 4
Date: Aug 8, 2019
Visit Reason
Health resurvey to assess compliance with previously cited deficiencies related to care plan revisions, respiratory care, drug regimen review, and psychotropic medication monitoring.
Findings
The facility failed to timely revise a comprehensive care plan for comfort care, ensure proper respiratory care and monitoring for a resident on opioids, and ensure the consultant pharmacist identified lack of monitoring specific targeted behaviors for residents on psychotropic medications. Documentation and monitoring of specific targeted behaviors for psychoactive medications were inadequate.
Deficiencies (4)
F657: The facility failed to timely revise the person-centered comprehensive care plan to include comfort care interventions for Resident 33.
F695: The facility failed to ensure necessary respiratory care and monitoring consistent with professional standards for Resident 46 receiving opioids, including failure to notify physician of low oxygen saturation levels.
F756: The facility failed to ensure the consultant pharmacist identified the lack of monitoring specific targeted behaviors for Residents 21, 51, and 20 receiving psychotropic medications.
F758: The facility failed to ensure Residents 21, 51, and 20 did not receive unnecessary psychotropic medications due to failure to monitor specific targeted behaviors as required by policy.
Report Facts
Facility census: 54
Residents sampled: 12
Residents reviewed for unnecessary medications: 5
Oxygen saturation levels: 82
Oxygen saturation levels: 86
Risperdal dosage: 0.5
Xanax dosage: 0.25
Buspirone dosage: 10
Clonazepam dosage: 0.5
Quetiapine dosage: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Consultant Pharmacist J | Consultant Pharmacist | Interviewed regarding failure to identify lack of behavior monitoring for residents on psychotropic 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 care for Resident 33 and 46 |
| Certified Nurse Aide E | Certified Nurse Aide | Interviewed regarding care plan use and resident behaviors |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: 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 addresses multiple deficiencies related to care plan updates, monitoring of vital signs including oxygen saturation, and monitoring of specific targeted behaviors for residents on psychotropic medications. The facility outlines corrective actions, staff education, policy updates, and ongoing audits to ensure compliance.
Deficiencies (4)
Tag #657: Resident #33's care plan was updated to include comfort care status. MDS Coordinators will audit care plans to identify missing orders or interventions.
Tag #695: Resident #46's vital signs, including oxygen saturation, were monitored and orders updated to include O2 sats twice weekly. Policies on vital signs and physician notifications were revised accordingly.
Tag #756: Orders were added to monitor specific targeted behaviors for residents R20, R21, and R51. Policies on psychotropic drugs and pharmacy consultant monitoring were updated.
Tag #758: Orders and policies were updated to monitor specific targeted behaviors for residents R20, R21, and R51. Charge nurses will be re-educated on chart checks and order entry procedures.
Report Facts
Deficiency tags cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian Koehn | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 5, 2018
Visit Reason
The document is a Plan of Correction submitted following a health survey of a long term care 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
Date: 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 no deficiency citations related to the applicable regulations for the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 23, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for regulatory compliance purposes.
Findings
No deficiencies were cited in the related inspection report dated 02/23/2016.
Inspection Report
Deficiencies: 0
Date: Nov 6, 2014
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
Census: 55
Deficiencies: 1
Date: Jul 25, 2013
Visit Reason
The inspection was conducted to assess compliance with nursing facility regulations, specifically regarding the emergency call system and related support 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 facility's policy did not address the requirement for an enunciator panel or monitor system in all nurses work stations.
Deficiencies (1)
26-40-303 (b)(i)(ii)(iii)(iv)(c) Nursing facility support system requires an emergency call system with audible and visual signals at nurses work stations. The facility lacked an enunciator panel or monitor screen at the Cottonwood Hall nurses work station.
Report Facts
Resident census: 55
Residents housed in Cottonwood Hall: 22
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jun 7, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously reported deficiencies under regulations 483.20(b)(1), 483.25(h), 483.25(l), and 483.60(c) were corrected by the revisit date of 06/07/2012.
Deficiencies (4)
Regulation 483.20(b)(1): Previously cited deficiency was corrected by 06/07/2012.
Regulation 483.25(h): Previously cited deficiency was corrected by 06/07/2012.
Regulation 483.25(l): Previously cited deficiency was corrected by 06/07/2012.
Regulation 483.60(c): Previously cited deficiency was corrected by 06/07/2012.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: May 25, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey.
Findings
The facility outlines corrective actions including development and implementation of policies for resident assessments, fall risk management, medication monitoring, and ongoing audits to ensure compliance.
Deficiencies (4)
F272-D: The facility must conduct comprehensive, accurate, and standardized assessments of each resident's functional capacity and ensure completion of assessments with updated care plans.
F323-D: Residents with falls or high fall risk must be identified promptly, with fall risk assessments completed before the end of the shift the fall occurred, and individualized care plans developed.
F329-D: The facility must monitor bowel movements and blood pressures for specific residents, audit drug regimens for contraindications, and educate nursing staff on physician notification protocols.
F428-D: The facility must review all residents and provide the pharmacy consultant with a full incident log during monthly reviews, including fall and vital sign data, with compliance measured through risk management and D.O.N. review.
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 4
Date: May 8, 2012
Visit Reason
The inspection was a health facility resurvey to evaluate compliance with comprehensive assessments, accident prevention, drug regimen appropriateness, and pharmacy reporting requirements.
Findings
The facility failed to conduct comprehensive assessments for 3 sampled residents, ensure adequate supervision to prevent accidents for 1 resident, maintain drug regimens free from unnecessary drugs for 2 residents, and ensure the pharmacist reported medication irregularities to the physician and nursing director for 1 resident.
Deficiencies (4)
F 272: The facility failed to conduct periodic comprehensive assessments for 3 of 10 sampled residents, missing care area assessments and fall assessments.
F 323: The facility failed to ensure adequate supervision and assistance to prevent accidents for resident #19, with ineffective fall prevention interventions.
F 329: The facility failed to ensure drug regimens were free from unnecessary drugs by not adequately monitoring effectiveness and side effects for 2 residents.
F 428: The facility failed to ensure the pharmacist reported medication irregularities, including low blood pressure readings, to the attending physician and director of nursing for resident #19.
Report Facts
Resident census: 54
Residents sampled: 10
Residents with failed comprehensive assessments: 3
Residents with inadequate supervision: 1
Residents with unnecessary drug monitoring issues: 2
Low blood pressure readings: 2
Days without bowel movement documentation: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse B | Administrative Nurse | Confirmed failures in monitoring and documentation for residents #19 and #42 |
| Licensed nurse C | Licensed Nurse | Confirmed lack of timely assessments and fall prevention interventions for resident #19 |
| Consultant staff F | Pharmacy Consultant | Confirmed failure to review vital signs and report medication irregularities for resident #19 |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: N035001 POC 6LKL11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection of Bethel Home.
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' for each.
Deficiencies (4)
Deficiency F0000 was noted with no plan of correction required.
Deficiency F371-F was noted with no plan of correction required.
Deficiency F431-E was noted with no plan of correction required.
Deficiency S1166-E was noted with no plan of correction required.
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