Inspection Reports for Bethel Home

The complaint investigation found that staff used a mechanical lift without ensuring a safety latch was in place prior to transferring resident R1, resulting in R1 falling and sustaining a large acute subdural hematoma and other injuries. R1 was hospitalized and later passed away. The immediate jeopardy began on 7/30/25 and was corrected on 7/31/25.

The facility failed to ensure the resident environment was free from accident hazards by allowing staff to use a mechanical lift without a safety latch in place, leading to a resident fall with immediate jeopardy to resident health and safety. The facility corrected the immediate jeopardy by removing the lift from use, retraining staff, and implementing audits.

The facility failed to update the care plan for R1 to include recommendations from an Advanced Practice Nurse Prescriber regarding transfer speed and hydration. Additionally, the facility did not ensure a physician received and responded to the results of R1's clavicle X-ray, which showed a fracture.

The complaint investigation found that residents R50, R65, and R27 did not receive proper written transfer notices or bed hold notifications during hospital transfers. The facility acknowledged inconsistent provision of these notices, particularly for Medicaid residents due to automatic bed hold policies.

The facility did not ensure that 3 of 4 residents reviewed for hospitalization received transfer notices that included required information such as date, reason, location, appeal rights, and contact information for the State Long-Term Care Ombudsman. Additionally, the facility failed to provide proper bed hold notifications to these residents or their representatives, especially for Medicaid residents who were not consistently given these notices due to automatic bed hold policies.

The complaint investigation found substantiated issues including late transmission of RAI/MDS assessments for 14 residents, unsafe transfer practices for one resident (R33), and improper medication administration for the same resident (R33).

The facility failed to timely transmit RAI/MDS assessments for 14 residents, transferred one resident unsafely without required safety straps or therapy staff present, and allowed one resident to self-administer medication without a physician's order or proper assessment.

The complaint involved Resident 2's inappropriate sexual behavior towards Resident 1 and Resident 3, including fondling and making sexual comments. The facility initiated 15-minute checks and behavioral health medication review but failed to revise the care plan or adequately communicate incidents among staff. The investigation included staff interviews and review of progress notes, revealing lapses in monitoring and communication.

The facility failed to update and revise the care plan for R2 after interventions were found ineffective, and staff were not adequately informed about R2's behaviors and whereabouts during 15-minute checks. Staff interviews revealed inconsistent communication and monitoring, with R2 able to move quickly around the unit and enter another resident's room despite precautions.

Based on staff interview and record review, the facility did not ensure a thorough investigation was completed to rule out abuse for a major injury of unknown origin for 1 Resident (R1) of 3 residents reviewed for abuse. The investigation did not include interviews with other residents to rule out potential abuse. The Nursing Home Administrator and Director of Nursing stated other residents were not interviewed because the unit was a dementia unit and residents could not respond to questions. Family members of the resident were interviewed, but other residents and/or family members were not.

The facility did not ensure a thorough investigation was completed to rule out abuse for a resident diagnosed with a left arm fracture. The investigation lacked interviews with other residents to rule out potential abuse, despite the facility's policy stating additional patients/elders are often interviewed.

The complaint investigation included issues of resident participation in care planning, mistreatment allegations, PASARR screening compliance, pressure ulcer care, dialysis care, and staff COVID-19 testing compliance. The allegation of mistreatment for resident R16 was not investigated by the facility.

The facility failed to ensure residents participated in quarterly care conferences, did not investigate an allegation of mistreatment, did not complete required PASARR Level II screenings, failed to provide appropriate pressure ulcer care, lacked a dialysis care plan and consistent communication with the dialysis center, and did not ensure required COVID-19 testing for a staff member not up-to-date with vaccination.