Bethany Lutheran Home

Inspectors wroteBased on Electronic Health Record (EHR) review, document review, staff interviews and policy review the facility failed to protect a resident from misappropriation of property when a resident's medication became missing from the facility for 1 of 3 residents reviewed (Resident #6). The facility reported a census of 86 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review the facility failed to protect a resident from possible accidents and injuries for 1of 2 residents (Resident #38). The facility failed to provide adequate supervision to prevent elopement. On 7/20/25 between 4:30-4:40 PM the staff last saw Resident #38 standing by the front door where visitors were exiting. The door alarm sounded with Staff A responding to the alarm but he failed to locate Resident #38 and went back to his previous duties being unaware Resident #38 was outside. On 7/20/25 at approximately 5:00 PM Staff B looked out the dining room window and observed Resident #38 walking down the sidewalk past the facility, near the bridge over a creek, towards a high traffic 3 lane street with a speed limit of 35 miles per hour. [...]

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices by not donning appropriate Personal Protective Equipment (PPE) or completing appropriate hand hygiene when personal care was completed and failed to provide appropriate infection prevention practices for waterborne pathogens for 5 of 24 residents reviewed (Resident #5, #8, #35, #89 and #77). The facility reported a census of 90 residents.

Inspectors wroteBased on observations, resident and staff interviews, document reviews and policy review the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 6 of 27 residents reviewed (Resident #35, #42, #10, #30, #50 and #76). The facility reported a census of 90.

Inspectors wroteBased on observations, resident and staff interviews, record review, and policy review the facility failed to complete a significant change comprehensive assessment when a resident had a decline in condition for 1 (Resident #76) of 3 residents reviewed. The facility reported a census of 90 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to complete a Pre-admission Screening and Resident Review (PASRR) for 1 of 1 residents (Resident #6), who was diagnosed with new mental disorder diagnoses since admission to the facility. The facility reported a census of 90 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to provide a comprehensive care plan related to high risk medications for residents with an order for diuretics for 1 of 5 residents (Resident #6) reviewed. The facility reported a census of 90 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review the facility failed to provide needed services in accordance with professional standards by leaving medications in a residents room for 2 of 8 residents (Resident #75 and #78). The facility reported a census of 90 residents.

Inspectors wroteBased on clinical record review, family interview, staff interviews, and policy review the facility failed to ensure the residents were free of significant medication errors to 1 of 4 residents reviewed (Resident #38). The facility reported a census of 90 residents.

Inspectors wroteBased on clinical record review, facility policy review, staff interviews, and the provider interview, the facility failed to ensure the orders of 1 of 3 residents (Resident #2) were implemented after a 30-day review was completed by the ordering Nurse Practitioner. Resident #2 was ordered morphine sulfate (opioid used to treat severe pain) 15 milligrams (mg) twice a day (BID) for pain. The order was a durational order to be reviewed every 30 days by the Nurse Practitioner for continued use. During the Nurse Practitioner's visit with the resident on 3/20/2025 she noted to continue with the scheduled and as needed (PRN) orders for morphine. The Nurse Practitioner documented on 3/31/2025 that staff notified the provider the resident had not received her scheduled morphine since the March 18, 2025. Facility phoning pharmacy to see what occurred. [...]

Inspectors wroteBased on clinical record view, observation, staff and resident interviews, and facility policy review the facility failed to transfer 1 of 4 residents (Resident #3) in a way that would prevent an accident. The facility reported a census of 88 residents.

Inspectors wroteBased on clinical record review, facility investigation file review, staff and resident interviews, and facility policy review the facility failed to treat 1 of 3 resident (Resident #3) with dignity during medication administration. The facility reported a census of 86 residents.

Inspectors wroteBased on clinical record review, facility investigation file review, staff and resident interviews, and facility policy review the facility failed to report an allegation of abuse involving Resident #3 within 2 hours of the allegation. The facility reported a census of 86 residents.

Inspectors wroteBased on observations, staff interviews, clinical record review, and policy review the facility failed to review and revise the Care Plans for 2 of 7 residents reviewed (Resident #5 and Resident #6). The facility failed to revise the interventions for a resident who sustained falls and a resident who had a significant change. The facility reported a census of 86 residents.

Inspectors wroteBased on clinical record review, facility investigation file review, staff interviews and facility policy review the facility failed to use professional standards while administering Resident #3's medications. The facility reported a census of 86 residents.

Inspectors wrote2. Resident #22's MDS assessment dated [DATE] identified a BIMS score of 15, indicating no cognitive impairment. The MDS listed Resident #22 as dependent or required partial assistance for toileting hygiene, bathing, and lower body dressing. In addition, Resident #22 required supervision or touching assistance for personal hygiene. The MDS included diagnoses of polio (a viral infection that can lead to partial or full paralysis), lack of coordination, muscle weakness, abnormalities of gait and mobility. In an interview on 10/28/24 at 12:34 PM, Resident #22 reported it took staff 45 minutes to answer his call light that morning. Resident #22 stated, they didn't have enough help. Resident #22 explained it took staff 20 to 30 minutes to answer the call light. Resident #22 added, he urinated in his chair because it took so long. It pissed him off when he had to urinate in his own chair. [...]

Inspectors wroteBased on the facility staff report and interviews the facility failed to provide Registered Nurse (RN) coverage for at least 8 consecutive hours a day for 7 days a week. The facility census was 85.

Inspectors wroteBased on observation, staff interview, and facility policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility reported a census of 85 residents.

Inspectors wroteBased on clinical record review and staff interviews the facility to notify the Long-Term Care (LTC) Ombudsman of a transfer to the hospital for 1 of 6 residents reviewed (Resident #26). The facility reported a census of 85 residents.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to offer the resident, the Resident's Representative, and/or the Power of Attorney (POA) of a bed hold for 1 of 6 residents reviewed (Resident #26). The facility reported a census of 85 residents.

Inspectors wrote2. Resident #36's MDS assessment dated [DATE] identified a Staff Assessment for Mental Status indicating they had moderately impaired cognitive skills for daily decision making. The MDS included diagnoses of anxiety disorder, psychotic disorder, and Parkinsonism. The Preadmission Screening and Resident Review (PASRR) Level I Screen Outcome, dated 11/6/20 listed a summary of findings as Resident #36 didn't show evidence of a serious mental illness or an intellectual or developmental disability(IDD) that required PASRR intervention. The document provided Resident #36 had a current diagnosis of anxiety disorder and received fluoxetine (antidepressant) 20 milligrams (mg) per (/) day. The document instructed to submit a new screen if changes occur or new information refutes the findings. Resident #36's Medical Diagnoses included the following diagnoses: a. 10/1/23: Parkinson's Disease. b. [...]

Inspectors wroteBased on clinical record review and staff interview the facility failed to address dementia care for 1 out of 3 residents reviewed (Resident #1). The facility reported a census of 85 residents.

Inspectors wroteBased on observation, facility policy review, and staff interview the facility failed to provide appropriate infection prevention practices when administering medications, providing personal care, catheter care, and wound care for 3 of 4 residents reviewed (Residents #1, #22 and #58). The facility reported a census of 85 residents.

Inspectors wroteBased on clinical record review, facility investigative file review, staff interviews and facility policy review the facility failed to prevent 1 of 3 residents (Resident #1) from sustaining an injury while assisting them with positioning in their bed. Resident #1's care plan documented she required the assistance of two staff with repositioning in bed. On 7/20/24 Resident #1 wanted to be repositioned in bed. Staff A Certified Nursing Assistant (CNA assisted Resident #1 by herself with repositioning in bed when she rolled out of bed and landed on the floor. Resident #1 complained of pain to her hip, left arm and indicated she did hit her head. Resident #1 was taken to the emergency room (ER) and found to have a closed displaced fracture of her left femoral neck that required surgical repair on 7/22/24. The resident returned to the facility on 7/24/24. [...]

Inspectors wroteBased on clinical record review, staff interviews and facility policy review the facility failed to follow 1 of 3 resident's (Resident #1) care plan while repositioning her in bed. The facility reported a census of 84 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, resident interviews, facility investigative files and facility policy review the facility failed to treat 5 of 5 residents (Resident #2, #5, #6, #7, and #8) with dignity and respect. The facility reported a census 85 residents.

Inspectors wroteBased on observations, clinical record review, resident interviews, staff interviews, facility investigative file review and facility policy review, the facility failed to transfer 2 of 3 residents (Resident #5 and #6) in a manner to prevent any accidents and hazards. Staff transferred Resident #5 using a mechanical lift and one staff member. Staff also attempted to transfer Resident #6 with one staff instead of two. The facility reported a census of 85 residents.

Inspectors wroteBased on clinical record review, staff interviews, transportation driver interview, clinic staff interview, family interviews, facility document review and facility policy the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice. A nurse failed to complete an assessment and intervene with a significant change. The resident was unresponsive prior to leaving for an appointment, after Oxycodone a schedule 2 opiate (narcotic) was given. At the clinic appointment the resident was found to be unresponsive with a blood pressure of 62/38 and a faint pulse. Narcan, an opiate antagonist was given. Primary diagnosis at appointment was unresponsiveness. Resident #1 was transferred to the emergency room from the clinic via ambulance. [...]

Inspectors wroteBased on electronic health records review, facility policy review, and staff interview the facility failed to provide a professional standard of quality by not following physician orders for 1 of 5 residents reviewed (Resident #1). The facility reported a census of 90 residents.

Inspectors wroteBased on clinical record review, facility policy review, physician interviews and staff interviews the facility failed to provide respiratory care and services by sending a resident to an appointment without oxygen when oxygen was required to 1 of 1 residents reviewed (Resident #192). The facility reported a census of 87 residents.

Inspectors wroteBased on clinical record review, facility record review, facility policy review, resident interview, and staff interview, the facility failed to answer call lights in a timely manner for 4 of 18 residents reviewed (Residents #50, #72, #10, and #195). The facility reported a census of 87 residents.

Inspectors wroteBased on observation, clinical record review, resident interviews and staff interviews the facility failed to provide privacy during personal cares to 1 of 3 residents reviewed (Resident #10). The facility reported a census of 87 residents.

Inspectors wroteBased on resident interview, staff interviews and document review the facility failed to ensure grievances were reported and followed through for 1 of 1 residents reviewed (Resident #195). Resident #195 reported to Staff T that a wallet was missing and no investigation was completed. The facility reported a census of 87 residents.

Inspectors wroteBased on clinical record review, facility policy review, and staff interview, the facility failed to obtain a bed hold within 24 hours of a hospitalization for 3 of 5 residents reviewed (Resident #1,#52, and #65). The facility reported a census of 87 residents.

Inspectors wrote2. The annual MDS assessment dated [DATE] revealed Resident #52 had diagnoses of septicemia, diabetes, and right lower limb cellulitis. The MDS revealed the resident readmitted to the facility from the hospital on 6/2/23. The MDS documented the resident received antibiotics 6 of 7 days during the look-back period and received IV medication. Resident #52's Care Plan revised 6/26/23 revealed the resident at risk for COVID-19 related to multiple comorbidities. The goal included the resident will remain free of COVID-19 infection through the review target date 10/24/23. The Care Plan lacked information about the resident's current infection of septicemia and cellulitis, PICC line monitoring, care and use, and intravenous (IV) antibiotic use and monitoring. [...]

Inspectors wroteBased on clinical record review and staff interview, the facility failed to adhere to professional standards of quality for assessing and diagnosing a resident with a new order for an antipsychotic medication for 1 of 1 resident reviewed (#39). The facility identified a census of 87 residents.

Inspectors wroteBased on observation, and clinical record review the facility failed to provide proper positioning in a wheelchair of appropriate size for 1 of 1 resident reviewed (#53). The facility reported a census of 87.

Inspectors wroteBased on clinical record review, and staff interviews, the facility failed to provide necessary treatment to prevent developing avoidable pressure ulcers for 1 of 2 resident reviewed (Resident #25). The facility reported a census of 87.

Inspectors wroteBased on clinical record review, observations, resident interview, family interview, staff interviews, and facility policy review the facility failed to prevent unsupervised falls and failed to provide transfers with appropriate number of staff for 3 of 3 (Resident #1, #9, and #72) residents reviewed. The facility reported a census of 87 residents.

Inspectors wroteBased on observations, clinical record review, resident interviews and staff interviews the facility failed to ensure a resident was not catheterized unless clinically necessary, failed to receive appropriate care to prevent urinary tract infections (UTI) when has a catheter and failed to provide incontinence care for 2 of 2 residents reviewed for catheters and incontinence (Resident #76 and #10). The facility reported a census of 87 residents.

Inspectors wroteBased on clinical record review, facility policy review and staff interviews the facility failed to provide dialysis services consistent with professional standards by not completing a post dialysis assessment to 1 of 1 residents reviewed (Resident #84). The facility reported a census of 87 residents.

Inspectors wrote3. The MDS dated [DATE] for Resident #191 revealed a BIMS of 13out of 15 indicating intact cognition. The MDS further revealed diagnosis of diabetes mellitus, hemiplegia affecting left nondominant side, and pulmonary fibrosis. Review of the MAR dated July 2023 revealed an order for PEG-3350/KCL SOL/Sodium drink 2L of solution by mouth beginning at 4 PM. The MAR further revealed an order for PEG-3350/KCL SOL/Sodium finish drinking the remaining 2L by mouth at 8PM. The MAR revealed both orders had been signed off as completed by Staff G. Interview 8/16/2023 at 6:10 PM with Resident #191's family member stated solution was still sitting on the nightstand when she entered the facility and Resident #191 was still drinking the solution on the way to the appointment on 7/28/2023. [...]

Inspectors wroteBased on observation, clinical record review, Centers for Disease Control and Prevention (CDC), facility policy review, and staff interview the facility failed to perform hand hygiene during toileting and/or incontinence care for 2 of 8 residents reviewed (Resident #72 and #10). The facility reported a census of 87 residents.