Inspection Reports for Bethel Pointe Health and Rehab
3400 W COMMUNITY DR, MUNCIE, IN, 47304
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 21, 2025, found Bethel Pointe Health and Rehab in compliance with applicable federal and state regulations during the paper review for recertification and licensure. Earlier inspections showed a pattern of deficiencies primarily related to life safety code compliance, medication management, and resident care issues such as wound treatment and tube feeding site care. Complaint investigations were mostly unsubstantiated, though some substantiated complaints cited deficiencies involving medication storage, wound care, and fall prevention, including one incident resulting in resident injury. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s recent clean recertification survey suggests improvement following prior citations in several areas.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
94% occupied
Based on a April 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 21, 2025
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey conducted on March 21, 2025.
Findings
Bethel Pointe Health and Rehab was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 107
Capacity: 114
Deficiencies: 3
Date: Apr 9, 2025
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with exit door operation, hazardous area enclosures, and fire extinguisher inspection documentation. Corrective actions were planned and initiated.
Deficiencies (3)
Failed to ensure 1 of 2 exit doors from the Therapy Room required only one operation to open due to a sliding bolt lock.
Failed to ensure 2 of over 13 hazardous areas such as fuel-fired heater rooms were separated from other spaces by smoke resistant partitions and doors that were self-closing or automatic closing.
Failed to ensure 1 of 26 portable fire extinguishers were inspected at least monthly and inspections were documented including date and initials.
Report Facts
Certified beds: 114
Census: 107
Deficiencies cited: 3
Fire extinguishers: 26
Hazardous areas: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Selina Holloway | HFA | Laboratory Director's or Provider/Supplier Representative's signature on the report |
| Director of Plant Operations | Interviewed regarding deficiencies related to exit door operation, hazardous area enclosures, and fire extinguisher inspections |
Inspection Report
Life Safety
Deficiencies: 0
Date: Apr 9, 2025
Visit Reason
The Life Safety Code Recertification and State Licensure Survey was conducted to assess compliance with fire safety and state licensure requirements.
Findings
Bethel Pointe Health and Rehab was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Renewal
Census: 103
Deficiencies: 3
Date: Mar 21, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00455970.
Complaint Details
Complaint IN00455970 was investigated during the survey; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the complaint allegations were cited. The facility was cited for deficiencies including failure to provide proper tube feeding site care for one resident, failure to post complete nurse staffing information daily, and failure to date insulin vials and pens when opened.
Deficiencies (3)
Failed to provide services for a resident with a feeding tube to prevent complications for 1 of 1 resident reviewed for tube feeding (Resident 47).
Failed to post complete nurse staffing information daily for residents and visitors, potentially affecting all 103 residents.
Failed to ensure insulin vials and pens were dated when opened and disposed of when expired for 2 of 5 medication carts reviewed.
Report Facts
Census: 103
Nurse staffing hours: 40
Nurse staffing hours: 64
Nurse staffing hours: 71.25
Census: 99
Registered Nurse hours: 32
Licensed Practical Nurse hours: 64
Certified Nurse Aide hours: 75
Census: 98
Registered Nurse hours: 32
Licensed Practical Nurse hours: 64
Certified Nurse Aide hours: 67.5
Census: 101
Registered Nurse hours: 32
Licensed Practical Nurse hours: 64
Certified Nurse Aide hours: 67.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Selina Holloway | HFA | Signed the report and provided facility policy information |
| RN 4 | Observed medication storage and insulin dating issues on East hall cart | |
| LPN 5 | Observed medication storage and insulin dating issues on Center hall cart | |
| LPN 6 | Interviewed regarding feeding tube site care documentation and procedures | |
| LPN 7 | Interviewed regarding feeding tube site care orders and documentation | |
| Director of Nursing | DON | Provided facility policies and interviews regarding feeding tube care and nurse staffing postings |
| Corporate Nurse Consultant | Interviewed regarding feeding tube site care assessment |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 0
Date: Mar 5, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00453467 and IN00454798.
Complaint Details
Investigation of Complaints IN00453467 and IN00454798 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00453467 and IN00454798 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 103
Census Bed Type - SNF/NF: 93
Census Bed Type - SNF: 10
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 56
Census Payor Type - Other: 37
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 0
Date: Jan 10, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00449433.
Complaint Details
Complaint IN00449433 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00449433 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 106
Medicare residents: 34
Medicaid residents: 51
Other payor residents: 21
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Date: Nov 13, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00443196.
Complaint Details
Complaint IN00443196 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations regarding the complaint investigation.
Report Facts
Census Bed Type Total: 90
Census Bed Type SNF/NF: 85
Census Bed Type SNF: 5
Census Payor Type Medicare: 5
Census Payor Type Medicaid: 47
Census Payor Type Other: 38
Inspection Report
Complaint Investigation
Census: 98
Capacity: 98
Deficiencies: 1
Date: Sep 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441065 regarding federal and state deficiencies related to wound care.
Complaint Details
Complaint IN00441065 was substantiated with federal/state deficiencies cited at F684 related to wound care treatment and documentation failures.
Findings
The facility failed to complete ordered wound treatments and assessments for 2 of 3 residents reviewed for wound care, specifically Residents B and C. Documentation of treatments and drainage assessments was missing on multiple dates.
Deficiencies (1)
Failed to complete ordered wound treatments and assessments for 2 of 3 residents reviewed for wound care (Residents B and C).
Report Facts
Census: 98
Total Capacity: 98
Medicare Residents: 10
Medicaid Residents: 52
Other Payor Residents: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Selina Holloway | HFA | Signed as Laboratory Director or Provider/Supplier Representative |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 6, 2024
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00441065 completed on September 6, 2024.
Complaint Details
Investigation of Complaint IN00441065 completed on September 6, 2024; facility found in compliance.
Findings
Bethel Pointe Health and Rehab was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 12, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00437074 completed on July 12, 2024.
Complaint Details
Investigation of Complaint IN00437074 completed on July 12, 2024; paper compliance review found the facility in compliance.
Findings
Bethel Pointe Health and Rehab was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 1
Date: Jul 11, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00437074 and IN00436772. Complaint IN00437074 resulted in federal/state deficiencies related to medication storage and disposal, while complaint IN00436772 had no deficiencies cited.
Complaint Details
Complaint IN00437074 was substantiated with federal/state deficiencies cited at F761 related to medication storage and disposal. Complaint IN00436772 had no deficiencies related to the allegations.
Findings
The facility failed to ensure medications were stored securely and disposed of according to policy and compliance regulations. Multiple medications for discharged residents were found improperly stored in an unlocked file cabinet in the Wound Nurse's office. Interviews confirmed medications should not be stored in offices and must be destroyed or sent with residents upon discharge. Facility policies on medication storage and drug disposition were reviewed and corrective actions including staff re-education and ongoing audits were planned.
Deficiencies (1)
Failure to ensure medications were stored securely and disposed of according to policy and compliance regulations.
Report Facts
Census: 104
Medications found: 24
Survey dates: 2
Residents discharged with medications found: 15
Audit frequency: 6
Audit frequency: 6
Medication retention days: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Selina Holloway | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Life Safety
Census: 103
Capacity: 114
Deficiencies: 4
Date: Jul 8, 2024
Visit Reason
The Indiana Department of Health conducted an Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey at Bethel Pointe Health and Rehab on 07/08/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included improperly secured egress doors with exit codes not posted, failure to maintain fire alarm system inspection documentation, corridor doors that did not close and latch properly, and improper use of power strips as substitutes for fixed wiring.
Deficiencies (4)
Means of egress through 9 facility exits were magnetically locked with exit codes not posted or unknown to staff.
Failure to maintain 1 of 1 fire alarm systems in accordance with NFPA 72; no documentation of semi-annual visual inspection was available.
Two corridor doors failed to close and latch properly, resisting passage of smoke.
Two power strips were used as substitutes for fixed wiring to power high current draw equipment.
Report Facts
Certified beds: 114
Census: 103
Number of deficient egress doors: 9
Number of corridor doors with closure issues: 2
Number of power strips misused: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Selina Holloway | HFA | Signed the report |
| Director of Plant Operations | Interviewed and acknowledged findings related to egress doors, fire alarm system, corridor doors, and power strips | |
| Administrator | Interviewed and acknowledged findings | |
| Regional Maintenance Support representative | Interviewed and acknowledged findings |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jul 8, 2024
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 07/08/24.
Findings
Bethel Pointe Health and Rehab was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Census: 103
Capacity: 103
Deficiencies: 3
Date: Jun 7, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of four complaints (IN00435685, IN00435804, IN00435137, and IN00433981).
Complaint Details
Complaint IN00435685, IN00435804, and IN00435137 had no deficiencies related to the allegations. Complaint IN00433981 had deficiencies related to pressure injury, catheter care, and medication administration.
Findings
The facility was found deficient in several areas including failure to obtain an apical pulse prior to digoxin administration, inadequate monitoring and treatment of a pressure injury, and improper positioning of an indwelling catheter and tubing leading to contamination risk. Some complaints were substantiated with deficiencies cited, while others had no deficiencies related to allegations.
Deficiencies (3)
Failed to ensure an apical pulse was obtained prior to administration of digoxin for 1 of 8 residents observed during medication administration (Resident 58).
Failed to provide monitoring and implement interventions to promote healing of a pressure injury for 1 of 3 residents reviewed for pressure injuries (Resident C).
Failed to ensure an indwelling catheter and tubing was positioned properly to avoid contamination for 1 of 1 residents reviewed with urinary catheter (Resident C).
Report Facts
Census Bed Type - SNF/NF: 96
Census Bed Type - SNF: 7
Total Census: 103
Medicare Census: 7
Medicaid Census: 52
Other Payor Census: 44
Deficiency Completion Date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Selina Holloway | Laboratory Director or Provider/Supplier Representative | Signed the inspection report |
| RN 3 | Nurse observed failing to obtain apical pulse prior to digoxin administration for Resident 58 | |
| LPN 4 | Interviewed regarding pulse and blood pressure checks with digoxin administration | |
| LPN 5 | Interviewed regarding digoxin levels and pulse/blood pressure monitoring | |
| DON | Director of Nursing | Interviewed regarding expectations for pulse checks and catheter care |
| Wound Nurse | Provided wound treatment observations and interviews regarding pressure injury care | |
| CNA 7 | Interviewed regarding catheter care and pressure injury monitoring | |
| LPN 9 | Observed and interviewed regarding catheter care | |
| CNA 10 | Observed providing care to Resident C | |
| Physician Assistant | PA | Interviewed regarding documentation of pressure sore |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 7, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey, including investigation of Complaint IN00433981.
Complaint Details
Investigation of Complaint IN00433981 was included in the review and found to be in compliance.
Findings
Bethel Pointe Health and Rehab was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the recertification, state licensure survey, and complaint investigation.
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Date: May 6, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00429710 and IN00429167.
Complaint Details
Investigation of Complaint IN00429710 and IN00429167 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00429710 and IN00429167 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type Total: 107
Census Payor Type Total: 107
SNF/NF Beds: 96
SNF Beds: 11
Medicare Residents: 11
Medicaid Residents: 58
Private Pay Residents: 13
Other Pay Residents: 25
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 0
Date: Jan 11, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00425753, IN00425815, and IN00424993.
Complaint Details
Complaints IN00425753, IN00425815, and IN00424993 were investigated with no deficiencies found related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00425753, IN00425815, and IN00424993 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 101
Census SNF/NF beds: 91
Census SNF beds: 10
Census Medicare residents: 14
Census Medicaid residents: 55
Census Other payor residents: 32
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
Date: Dec 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00423806 and IN00419184.
Complaint Details
Investigation of Complaints IN00423806 and IN00419184 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in Complaints IN00423806 and IN00419184 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 89
Census Bed Type - SNF: 13
Total Census: 102
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 55
Census Payor Type - Other: 37
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 0
Date: Oct 2, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00418794 and IN00418253.
Complaint Details
Complaint IN00418794 and Complaint IN00418253 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in Complaints IN00418794 and IN00418253 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 96
Census Bed Type - SNF: 8
Census Bed Type - Total: 104
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 58
Census Payor Type - Other: 38
Census Payor Type - Total: 104
Inspection Report
Life Safety
Census: 105
Capacity: 114
Deficiencies: 0
Date: Jun 20, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 05/23/23 by the Indiana Department of Health.
Findings
At this Life Safety Code Survey, Bethel Pointe Health and Rehab was found in compliance with the Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.90(a).
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 0
Date: Jun 12, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00410083.
Complaint Details
Complaint IN00410083 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations of Complaint IN00410083 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type Total: 105
Census Bed Type SNF/NF: 95
Census Bed Type SNF: 10
Census Payor Type Medicare: 25
Census Payor Type Medicaid: 61
Census Payor Type Other: 19
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 8, 2023
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Bethel Pointe Health and Rehab was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 103
Capacity: 114
Deficiencies: 3
Date: May 23, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found not in compliance with life safety code requirements, including failure to maintain latching hardware on smoke barrier doors, unsealed penetrations in smoke barrier walls, and incomplete annual inspection documentation for fire door assemblies. Immediate corrective actions were taken and ongoing monitoring was planned.
Deficiencies (3)
Failed to maintain latching hardware on 3 of 3 smoke barrier doors which did not properly latch when tested.
Failed to ensure penetrations through smoke barrier walls were protected to maintain smoke resistance; unsealed penetration found above smoke door #2.
Failed to ensure annual inspection and testing of fire door assemblies was completed in accordance with NFPA 80; inspection records lacked door location identification and separate inspection sheets for each door.
Report Facts
Facility capacity: 114
Census: 103
Number of smoke barrier doors with faulty latching hardware: 3
Number of fire doors inspected on same sheet: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Derek Gibson | Director of Plant Operations | Named in findings related to latching hardware, smoke barrier penetrations, and fire door inspection deficiencies |
Inspection Report
Annual Inspection
Census: 107
Capacity: 107
Deficiencies: 6
Date: May 9, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00407948.
Complaint Details
Complaint IN00407948 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found deficient in several areas including call light accessibility for a dependent resident, failure to complete a significant change assessment after hospice admission, incomplete baseline care plans, medication administration errors, and improper infection control during wound care. No deficiencies were related to the complaint investigated.
Deficiencies (6)
Failed to ensure a call light was placed within reach of a dependent resident for 1 of 3 residents reviewed for activities of daily living.
Failed to complete a significant change assessment after hospice admission for 1 of 1 residents reviewed for hospice.
Failed to include activities of daily living needs in a baseline care plan for 1 of 3 residents reviewed for activities of daily living.
Failed to ensure medications were administered according to physician orders for 1 of 1 resident reviewed for diarrhea/constipation.
Medication error rate of 12% with 3 errors in 25 opportunities involving 1 of 7 residents observed for medication administration.
Failed to ensure infection prevention and control strategies were utilized during wound care for 1 of 3 residents reviewed for pressure ulcers.
Report Facts
Census: 107
Total Capacity: 107
Medication administration opportunities: 25
Medication administration errors: 3
Medication error rate: 12
Wound care observations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Derek Gibson | Administrator | Signed the report |
| LPN 3 | Named in wound care infection control deficiency | |
| LPN 5 | Interviewed regarding medication administration and resident care | |
| LPN 8 | Named in medication administration errors | |
| CNA 4 | Interviewed regarding resident care | |
| CNA 7 | Interviewed regarding call light placement | |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies and policies |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
This visit was conducted for the investigation of multiple complaints identified as IN00404415, IN00404021, IN00400209, IN00401833, IN00403444, IN00403829, and IN00403546.
Complaint Details
Investigation of Complaints IN00404415, IN00404021, IN00400209, IN00401833, IN00403444, IN00403829, and IN00403546 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF/NF: 92
Census SNF: 10
Total Census: 102
Census Payor Type Medicare: 27
Census Payor Type Medicaid: 56
Census Payor Type Other: 19
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 13, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00394932 completed on December 20, 2022.
Complaint Details
Complaint Investigation IN00394932 was reviewed and found to be in compliance.
Findings
Bethel Pointe Health and Rehab was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 98
Capacity: 98
Deficiencies: 1
Date: Dec 19, 2022
Visit Reason
This visit was for the investigation of four complaints (IN00394932, IN00394882, IN00395530, and IN00395785) at Bethel Pointe Health and Rehab.
Complaint Details
Complaint IN00394932 was substantiated with federal/state deficiencies cited at F658. Complaint IN00394882 was unsubstantiated due to lack of evidence. Complaints IN00395530 and IN00395785 were substantiated with no deficiencies related to the allegations cited.
Findings
The facility was found to have failed to ensure medication was administered under direct observation for a resident who did not self-administer medication, resulting in a substantiated complaint with related deficiencies cited. Other complaints were either unsubstantiated or substantiated with no deficiencies cited.
Deficiencies (1)
Failed to ensure medication was administered under direct observation for a resident who did not self-administer during a random observation.
Report Facts
Census: 98
Total Capacity: 98
Medicare Census: 9
Medicaid Census: 55
Other Payor Census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Derek Gibson | Administrator | Signed the report |
| QMA 5 | Named in medication administration deficiency for failing to administer and sign off medication | |
| LPN 7 | Licensed Practical Nurse | Interviewed regarding medication administration and findings |
| QMA 9 | Signed off medication administration after QMA 5 failed to do so | |
| ADON | Assistant Director of Nursing | Interviewed regarding medication administration and documentation |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 0
Date: Nov 18, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00395114.
Complaint Details
Complaint IN00395114 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The complaint IN00395114 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 106
SNF/NF beds: 93
SNF beds: 13
Medicare residents: 13
Medicaid residents: 55
Other payor residents: 38
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 0
Date: Nov 7, 2022
Visit Reason
This visit was conducted for the Investigation of Complaint IN00393448 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00393448 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The complaint IN00393448 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations regarding the complaint investigation and COVID-19 infection control.
Report Facts
Census: 106
SNF/NF beds: 90
SNF beds: 16
Medicare residents: 16
Medicaid residents: 55
Other payor residents: 35
Inspection Report
Complaint Investigation
Census: 105
Capacity: 105
Deficiencies: 1
Date: Oct 25, 2022
Visit Reason
This visit was for the investigation of Complaint IN00392098. The complaint was substantiated but no deficiencies related to the allegations were cited; an unrelated deficiency was cited.
Complaint Details
Complaint IN00392098 was substantiated. No deficiencies related to the allegations were cited; an unrelated deficiency was cited.
Findings
The facility failed to implement fall prevention interventions for one resident (Resident C) who was at high risk for falls. Resident C fell while in the shower, hitting his head, resulting in a subdural hematoma and other injuries. The facility's care plan and supervision were inadequate to prevent the fall, and staff did not follow required protocols for assistance and protective device use.
Deficiencies (1)
Failure to implement fall prevention interventions for Resident C, a high fall risk resident, resulting in a fall and head injury.
Report Facts
Census: 105
Total Capacity: 105
Medicare Census: 16
Medicaid Census: 55
Other Payor Census: 34
Fall Risk Assessment Date: Mar 24, 2022
Fall Incident Date: May 17, 2022
Plan of Correction Completion Date: Nov 16, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Derek Gibson | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Rachel | Certified Nursing Assistant (CNA) | Was present during Resident C's fall and attempted to prevent the fall |
| RN 3 | Registered Nurse | Interviewed regarding the fall incident and resident care |
| PT 2 | Physical Therapist | Provided information on resident's assistance needs and therapy status |
| CNA 6 | Certified Nursing Assistant | Responsible for Resident C in the shower at time of fall |
| CNA 7 | Certified Nursing Assistant | Assisted during the fall incident and provided interview information |
| DON | Director of Nursing | Provided interview and facility policy information |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 25, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00392098.
Complaint Details
Investigation of Complaint IN00392098 completed on October 25, 2022; facility found in compliance.
Findings
Bethel Pointe Health and Rehab was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
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