Bethany Home, Inc

Inspectors wroteBased on observations, interviews, and record reviews; the facility failed to ensure meals were served within the allotted time frames set forth by the facility staff. This had the potential to affect all residents served from the kitchen. The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(A) Based on record review, interview, and observation, the facility failed to ensure that all individuals with beards and moustaches wore beard and moustache coverings, and the facility failed to ensure a safe and effective cleaning routine and process for changing the filtration system of the facility ice machine. This had the potential to affect all residents residing in the facility. The Census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(D) Licensure Reference Number 175 NAC 12-006.05(E) Based on record review and interview the facility failed to ensure that the resident/resident representative was informed of the risks, benefits, and alternative treatments for the use of antipsychotic medication (any medication that affects behavior, mood, thoughts, or perception used to manage psychotic disorders) as required for 2 of 2 residents reviewed (Residents 59 and 42). The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(D) Based on record review and interview, the facility failed to ensure psychotropic medications had approved indications for use for 2 (Residents 58 and 42) of 5 sampled residents. The facility census was 62.

Inspectors wroteBased on record review and interview the facility failed to notify the ombudsman (a state appointed advocate for residents of nursing homes) of resident discharge for 1 of 1 residents reviewed (Resident 63) as required. The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(A)(i) Based on record review and interview the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Nebraska Level 1 Form (an initial pre-screening for mental illness and intellectual/developmental disabilities prior to admission) screening was completed prior to resident admission into the facility for 1 of 5 sampled residents (Resident 34). The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview, the facility failed to review and revise the comprehensive care plan with new interventions after each fall for one (Resident 15) of one resident sampled. The facility census was 62.

Inspectors wroteLicensure refernce number 175 NAC 12-006.11E Based on observation, interviews and record review, the facility failed to ensure food safety requirements by not removing dented cans for resident consumption, maintaining correct placement of hairnets while prepping and plating food, preforming hand hygiene for 20 seconds prior to plating residents' food, failure to prevent contamination by improperly holding dining plates while serving the residents meals, and improper storage of the fountain dispenser line. This has the potential to affect 62 residents in the facility. The facility identifies a census of 62 residents.

Inspectors wroteLicensure reference 175 NAC 12-006.05 (21) Based on observation, interviews, and record review, the facility failed to treat for 1 (Resident 24) of 1 sampled residents with dignity by asking them regarding their personal bowel habits while seated at the table in the dining room with their table mates. The facility identified a census is 62. An observation on 04/30/2024 at 12:00 PM while in the dining area, Registered Nurse-A (RN-A) approached Resident 24 while they were seated at their assigned seat for meals. RN-A held a conversation with Resident 24 regarding their bowel habits. This conversation was loud enough for Resident 24 table mates to hear the conversation and this observer to hear across the room. An interview on 05/01/2024 at 1:24 PM with Resident 24, confirmed they would prefer personal bowel habits are kept private. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10A1 Based on observation, record review and interview; the facility staff failed to evaluate 1 (Resident 42) of 3 sampled residents' ability to self-medicate. The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D6 Based on interviews, observations, and record reviews, the facility failed to provide cleaning for 1 (Resident 55) of 1 sampleted residents CPAP equipment. The facility has census of 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12E1 Licensure Reference Number 175 NAC 12-006.12E7 Based on observation, interview, and record review; the facility failed to keep a medication cart locked when out of eyesight of a nurse and failed to label and date an eye drops for 1 (Resident 1) of 3 sampled residents. The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17B Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review, and interview; the facility failed to perform hand hygiene between residents during medication administration and used bare fingers to pick up a dropped medication on the medication cart and the facility failed to perform hand hygiene according to facility policy during resident care for 3 (Resident 1, 32, 42) of 3 sampled residents. The facility census was 62.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview, and record review; the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and food was served and stored in a manner to prevent potential cross contamination. This had the potential to affect all 62 residents who received food from the facility kitchen. The facility identified a census of 62 at the time of survey.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation, interview, and record review; the facility staff failed to perform hand hygiene to prevent potential cross contamination during meal service. This had the potential to affect all of the 41 facility residents who ate their meal in the HCU (Health Care Unit) dining room. The facility identified a census of 62 at the time of survey.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.11A1 Based on observation, interview, and record review; the facility staff failed to follow the menu during meal service for the residents. This affected 16 of the 62 residents who were served the lunch meal, Residents 10, 22, 61, 6, 9, 52, 60, 23, 15, 18, 1, 14, 21, 45, 16, and 40. The facility identified a census of 62 at the time of survey.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (6) Based on observation, interview, and record review; the facility failed to promote resident dignity with dining by failing to serve each resident seated at the same table before moving on to the next table. This affected 3 (Residents 30, 14, and 45) of 41 residents seated in the facility dining room. The facility identified a census of 62 at the time of survey.

Inspectors wroteB. Record review of Resident 27's Quarterly MDS dated [DATE] revealed an admission date of 11/18/22. Antipsychotic medication was received 7 days of the 7-day MDS look back period. Has a gradual dose reduction (GDR) been attempted was marked no. Physician documented GDR as clinically contraindicated was marked yes with the date listed as 11/18/2022. Record review of Resident 27's Resident Safety Concerns dated 5/25/2023 revealed documentation Resident 27 had an order for Seroquel 100 mg by mouth every day with an order date of 11/18/2022. There was documentation the RP requested the physician review the psychotropic med list. The MD checked there are no medication adjustments recommended for this resident at this time. The Comment (by physician) was blank. [...]

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.11B Based on observation, interview, and record review; the facility failed to ensure all of the facility residents received 3 meals per day. This affected 1 of 41 residents who were served in the main dining room, Resident 63. The facility identified a census of 62 at the time of survey.