Inspection Reports for Samaritan Bethany Inc.
24 8th St NW, Rochester, MN 55901, United States, MN
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
28% worse than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 12, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with resident care standards, specifically focusing on whether residents' call lights were accessible to meet their needs and preferences.
Findings
The facility failed to ensure that call lights were accessible to 2 of 2 residents reviewed, which could prevent residents from effectively requesting assistance. Observations and interviews confirmed that call lights were out of reach, posing a risk to resident safety.
Deficiencies (1)
Failed to accommodate resident needs by ensuring the call light was accessible for 2 of 2 residents reviewed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Stated expectation that call lights should be in reach of all residents and confirmed findings regarding residents R60 and R187. | |
| Nursing Assistant (NA)-A | Interviewed and stated call lights should always be in reach of patients. | |
| Nursing Assistant (NA)-B | Interviewed and stated call lights should always be in reach of patients to prevent falls. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 14, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow care plans for resident transfers, resulting in falls and injuries.
Complaint Details
The complaint investigation focused on a fall incident involving resident R1 on 3/4/24, where the facility failed to follow the care plan for transfers, leading to serious injuries. The investigation also revealed a medication error involving incorrect aspirin dosing for R1.
Findings
The facility failed to follow care plans for transfers for residents R1 and R4, leading to a fall with major injury for R1, including traumatic brain injury and fractures requiring ICU hospitalization. Additionally, a medication transcription error was found where R1 received incorrect aspirin doses for 14 days.
Deficiencies (2)
Failure to follow care plan for transfers to prevent falls, resulting in actual harm to resident R1 with serious injuries.
Failure to accurately transcribe physician's orders into the electronic health record, resulting in resident R1 receiving 14 wrong doses of aspirin.
Report Facts
Fall risk assessment score: 28
Fall risk assessment score: 22
Days wrong aspirin dose administered: 14
ICU hospitalization days: 8
Date of fall: Mar 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA-A | Nursing Assistant | Involved in transferring resident R1 during fall incident |
| LPN-B | Licensed Practical Nurse | Assisted with resident R1 after fall and completed assessment |
| RN-A | Registered Nurse | Involved in investigation of resident R1's fall |
| TPD-A | Therapy Program Director | Verified care plan orders for resident R1 transfers |
| NA-D | Nursing Assistant | Involved in transferring resident R4 without using walker as per care plan |
| DON | Director of Nursing | Oversaw investigation of resident R1's fall and medication error |
| LPN-A | Licensed Practical Nurse | Worked day shift after resident R1's fall and coordinated care |
| NA-B | Nursing Assistant | Worked evening shift on day of resident R1's fall |
| LPN-C | Licensed Practical Nurse | Assessed resident R1 for pain during night shift after fall |
| NA-C | Nursing Assistant | Heard report of resident R1's fall during night shift |
Inspection Report
Routine
Capacity: 84
Deficiencies: 7
Date: Feb 1, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, resident care, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to properly assess and care plan for medication self-administration, inadequate posting of survey results, insufficient personal hygiene care (nail care), lack of timely repositioning and pressure ulcer prevention, incomplete bowel incontinence reassessment, failure to ensure completion of ordered laboratory tests, and inadequate infection prevention practices including improper PPE use and blood draw procedures.
Deficiencies (7)
Failed to comprehensively assess and care plan for self-administration of medications for resident R48, who was left with prepared medications without proper evaluation or physician approval.
Failed to ensure the most recent survey results were posted in a prominent and readily accessible location for residents and visitors.
Failed to provide routine personal hygiene care, specifically nail care, to resident R76, resulting in visibly long and soiled fingernails.
Failed to comprehensively reassess and develop interventions to ensure timely repositioning and appropriate pressure ulcer care for resident R60 at high risk for skin breakdown.
Failed to comprehensively reassess developed bowel incontinence and implement appropriate interventions for resident R13, despite complaints and multiple incontinent episodes.
Failed to ensure completion of a laboratory test ordered for resident R11 related to urinary tract infection evaluation.
Failed to ensure appropriate use of PPE for COVID-19 positive residents, including lack of fit testing for N95 masks, and failed to ensure blood draws were performed in appropriate settings to prevent infection and maintain dignity.
Report Facts
Residents affected: 1
Residents affected: 84
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-C | Licensed Practical Nurse | Named in medication self-administration finding for leaving medications with resident R48 |
| LPN-A | Licensed Practical Nurse | Interviewed regarding medication self-administration and personal hygiene care deficiencies |
| RN-A | Registered Nurse | Interviewed regarding medication self-administration and personal hygiene care deficiencies |
| NA-B | Nursing Assistant | Observed providing breakfast to resident R48 during medication administration |
| NA-C | Nursing Assistant | Interviewed regarding personal hygiene care and pressure ulcer care deficiencies |
| LPN-D | Licensed Practical Nurse | Interviewed regarding personal hygiene care and bowel incontinence deficiencies |
| LPN-B | Licensed Practical Nurse | Interviewed regarding laboratory test completion and blood draw infection control deficiencies |
| ACM | Assistant Clinical Mentor | Interviewed regarding infection control and laboratory test follow-up deficiencies |
| DON | Director of Nursing | Interviewed regarding infection control and laboratory test follow-up deficiencies |
| Administrator | Interviewed regarding survey results posting and blood draw infection control deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 11, 2023
Visit Reason
The inspection was conducted due to allegations of abuse involving resident R1, specifically regarding bruising and a skin tear sustained during care on 4/24/2023.
Complaint Details
The investigation was triggered by allegations of abuse to resident R1 involving bruising and a skin tear caused by nursing assistant NA-A on 4/24/2023. The facility investigation substantiated abuse occurred. The immediate jeopardy was identified and removed after corrective actions. The family was not notified timely of the injury. The facility failed to report the incident to the State Agency within the required 2-hour timeframe.
Findings
The facility failed to notify the family timely of a change of condition for resident R1 who sustained bruising and a skin tear during care. Nursing assistant NA-A did not follow R1's care plan, forcibly transferred R1 while she was refusing care, causing injury. The facility investigation substantiated abuse, identified immediate jeopardy which was removed after corrective actions, and found failure to timely report the incident to the State Agency within required timeframes.
Deficiencies (3)
Failed to notify family representative timely of change of condition for resident R1 who sustained bruising and skin tear during care.
Failed to protect resident R1 from abuse when staff forcibly transferred and restrained her causing bruising and skin tear, resulting in immediate jeopardy.
Failed to timely report suspected abuse to the State Agency within required 2-hour timeframe.
Report Facts
Skin tear size: 1
Bruise size: 3.5
Bruise size: 2.4
Bruise size: 2.5
Date of incident: Apr 24, 2023
Date of report: Apr 25, 2023
Date immediate jeopardy removed: Apr 27, 2023
Timeframe for reporting abuse: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA-A | Nursing Assistant | Identified as perpetrator causing bruising and skin tear to resident R1 during care on 4/24/2023 |
| NA-B | Nursing Assistant | Assisted NA-A during transfer of R1; held R1's legs down; did not feel comfortable correcting NA-A |
| LPN-A | Licensed Practical Nurse | Nurse on duty during incident; reported skin tear to acting administrator; did not notify family |
| LSW-A | Licensed Social Worker | Headed investigation; concluded abuse occurred; stated NA-A should have reported injury to family |
| ADON | Assistant Director of Nursing | Interviewed regarding incident; confirmed abuse and failure to follow care plan |
| DON | Director of Nursing | Interviewed regarding incident; confirmed abuse and failure to follow care plan |
| Acting Administrator | Administrator | Interviewed regarding incident; involved in decision to send NA-A home; confirmed abuse findings |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 28, 2022
Visit Reason
The inspection was conducted in response to complaints regarding the facility's failure to respond timely to resident grievances and concerns, including medication errors and inadequate activities for residents.
Complaint Details
The complaint involved failure to respond to grievances for resident R69, including concerns about medication errors and staff conduct. The complaint was substantiated with findings of inadequate grievance response and follow-up. Another complaint involved failure to provide meaningful activities for resident R11.
Findings
The facility failed to respond promptly to resident grievances and did not maintain records of informal concerns. Additionally, the facility failed to provide meaningful activities for one resident with cognitive impairment and physical limitations. Documentation and follow-up on medication errors were inadequate.
Deficiencies (2)
Failed to respond to resident grievances in a timely manner and failed to maintain records of grievances/concerns if not on formal grievance forms.
Failed to provide meaningful activities for a resident with cognitive impairment and physical limitations.
Report Facts
Residents affected: 1
Residents affected: 1
Date of medication error: Oct 1, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-C | Registered Nurse Care Coordinator | Lead staff on unit involved in grievance follow-up and medication error documentation |
| CN-B | Contract Nurse | Involved in medication error incident |
| DON | Director of Nursing | Facility clinical mentor and director of nursing involved in grievance and medication error follow-up |
| Facility Administrator | Community Leader | Facility administrator responsible for grievance follow-up and quality meetings |
| SW-B | Social Worker | Provided information on grievance policy and follow-up procedures |
| MD-A | Medical Director | Attended quality assurance meetings and commented on grievance discussions |
| NA-A | Nursing Assistant | Provided information on resident R11's activities and condition |
| ACT-A | Life Enrichment Mentor / Head of Activities Department | Discussed activities program and documentation for resident R11 |
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