Inspection Reports for
Homestead of Bethany

The complaint investigation found that the facility failed to report an abuse allegation within the required two-hour timeframe and failed to secure hazardous chemicals, posing immediate jeopardy to residents. The immediate jeopardy was lifted after the facility implemented corrective actions.

The facility failed to report an allegation of abuse within the required two-hour timeframe and failed to secure hazardous chemicals in the memory care unit, creating an immediate jeopardy situation that was later resolved.

The facility was found to have multiple deficiencies including inaccurate documentation of a resident's code status, incomplete comprehensive assessments within required timeframes, failure to transmit assessment data to CMS timely, and lack of a comprehensive care plan for one resident.

The facility failed to submit MDS assessment data on time for 3 of 6 sampled residents. Resident #61's assessment was still in progress and was submitted late. The administrator identified 51 residents residing in the facility at the time of inspection.

The facility failed to develop a diabetes care plan for one resident and had insufficient nursing staff levels from May through July 2024, potentially affecting all residents.

The complaint investigation found that staff did not follow infection control procedures during perineal care for Resident #1. The issue was substantiated based on observation and interviews.

The facility failed to ensure staff washed or sanitized their hands and changed gloves as needed during perineal care for one resident, potentially exposing the resident to infection. Staff did not follow infection control procedures, including wearing dirty gloves while touching the resident and bedding.

The investigation was complaint-driven based on allegations of missed bathing, inadequate nutrition, staffing shortages, and poor kitchen hygiene. The findings substantiated these complaints with documentation and staff interviews confirming the issues.

The facility failed to provide scheduled bathing for two residents, did not ensure double portions of food for a resident with a physician order, lacked sufficient nursing staff on multiple days, and failed to implement proper infection control and sanitary food distribution practices in the kitchen.

The facility was found deficient in multiple areas including incomplete and undated DNR forms, failure to complete background checks for new hires, incomplete resident assessments and transmissions, inaccurate MDS assessments, failure to make required PASRR referrals, inadequate ADL decline prevention, insufficient RN coverage and lack of a DON, incomplete staffing records, missing monthly medication regimen reviews, unnecessary psychotropic medication administration, absence of a dietary manager, failure to follow menus, improper food storage and sanitation, outdated facility assessment, lack of qualified social worker, and failure to sanitize equipment between residents.

The facility failed to provide adequate assistance with bathing and grooming for one resident and failed to ensure appropriate pressure ulcer care and assessments for another resident. Both deficiencies were identified with minimal harm and affected a few residents.

The center failed to ensure fire safety inspections were completed annually, with the last documented inspection dated July 13, 2021. The Executive Director confirmed no fire safety inspections had been conducted since that date.

The complaint investigation found that telephone use was restricted in the Memory Care Unit, with residents not allowed to use the phone from 6:00 p.m. to 6:00 a.m. One resident had telephone privileges removed due to the resident's husband making threats against the facility. The restriction and lack of privacy were confirmed by staff and the resident.

The facility failed to ensure one resident in the Memory Care Unit had reasonable access to a telephone and a private place to make calls. Telephone use was restricted from 6:00 p.m. to 6:00 a.m., calls were monitored by staff, and one resident had telephone privileges removed due to safety concerns.

The complaint investigation substantiated that staff failed to notify the physician of significant oxygen desaturation events and respiratory distress for one resident, leading to hospitalization and immediate jeopardy. The Oklahoma State Department of Health verified the immediate jeopardy on 05/01/23.

The facility failed to notify the physician of significant changes in oxygen saturation and respiratory status for one resident, resulting in hospitalization and immediate jeopardy to resident health. The facility submitted an acceptable plan of removal and educated staff on respiratory assessment and physician notification.

The facility was found deficient in multiple areas including failure to notify physicians of changes in resident conditions, inaccurate resident assessments, incomplete care plans for fall interventions, failure to provide scheduled showers, insufficient nursing staff, and improper food preparation and storage practices.

Deficiencies were found related to food storage, preparation and service, conduct of assessments, resident rights regarding medical care, and medication storage and administration. The deficiencies had the potential for more than minimal harm.

Deficiencies were found related to annual performance reviews for nurse aides, annual competency reviews for certified medication aides, hot water temperature exceeding standards, failure to complete annual fire marshal inspection, failure to ensure monthly medication reviews by qualified staff, and failure to obtain fingerprint-based background checks for certain employees. The deficiencies represented potential for more than minimal harm to residents.