Bethany St. Joseph Care Ctr

Inspectors wroteExample 3R50 was admitted to the facility on [DATE], and has diagnoses that include acute kidney failure, neuromuscular dysfunction of the bladder, type 2 diabetes mellitus, and cellulitis of buttock. R50 developed his pressure wound after admission. R50's MDS, dated [DATE], indicates that R50 is moderately cognitively impaired. R50's MDS shows that he requires substantial/maximal assist for hygiene and personal cares and is dependent for mobility. R50's physician orders dated 3/7/25 and 5/2/2025, state Encourage resident to lay down for at least 1 hr. on his SIDE between meals to offload pressure to buttocks twice a day AM PM. R50's Treatment Record (E-TAR) printed 6/17/25, shows the order was first implemented 5/23/25. No order for remainder 7 hours of the shift, resulting in R50 sitting on his buttocks for extended periods. R50's Kardex (CNA Resident Care Plan), dated 6/17/25, states: [...]

Inspectors wroteBased on observation, policy review, and interview, the facility failed to store, prepare, distribute and serve food in a manner that prevents foodborne illness to the residents. Male staff with facial hair did not wear beard restraints when over hot foods. This has the potential to affect all 68 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infections that has the potential to affect 10 residents living in that resident hall (R) (R3, R7, R20, R30, R37, R50, R60, R314, R315, R316). Facility staff failed to transport linens in a manner to prevent the spread of infection, potentially effecting all residents living in affected hallway. (R3, R7, R20, R30, R37, R50, R60, R314, R315, R316). Facility staff did not properly take on and take off personal protective equipment (PPE) during cares for R50, who is on enhanced barrier precautions (EBP). Facility staff failed to clean mechanical lift in between resident use. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure that residents with limited range of motion (ROM), received the appropriate treatment and services to maintain or prevent further reduction in ROM for 1 of 3 residents (R). (R22) R22's restorative plan was not implemented. R22 did not receive R22's maintenance program. This is evidenced by: The facility policy, titled Restorative Nursing Program, dated 8/15/06, states: To provide each resident with the opportunity to remain independent for as much and as long as possible despite impairment, disability, or handicap if he or she chooses . B. Nursing Responsibilities: 1. Document on resident cardex (sic) that resident is participating in a restorative nursing program. 2. Evaluate restorative nursing plan monthly with monthly nursing summary. 3. Monitor the effectiveness of program . C. CNA Responsibilities: 1. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) from the catheter for 1 of 3 residents (R) reviewed, R33. R33's Foley catheter was changed on a routine basis without clinical indications. This is evidenced by: Facility's policy titled, Indwelling Catheter Use and Removal, with a reviewed date of 01/25/25, states in part: Policy: It is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice .Catheters and drainage bags should be changed based on clinical indication such as infection, obstruction, or when the closed system is compromised. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident (R) who requires dialysis receives such service, consistent with professional standards of practice form 1 of 2 residents (R8) reviewed for dialysis. The facility failed to provide ongoing assessment of R8's condition and monitoring for complications before and after dialysis treatments. This is evidenced by: Facility policy titled, Dialysis Communication and Care, with an effective date of 01/26/18, states in part: Purpose: To ensure residents who require dialysis receive such services, consistent with professional standards of practice, their care plan and resident's goals and preferences. Procedure:1. Nursing will provide ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatment .3. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 1 resident (R59) reviewed for following physician orders.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure hand hygiene was conducted appropriately for 2 of 4 wound care observations (R32 and R65). This is evidenced by: The CDC had outlined the following indications for hand washing and the wearing of gloves: A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water. B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items. Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items. C. Decontaminate hands before having direct contact with patients . F. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility did not maintain an infection prevention and control program according to professional standards of practice when Enhanced Barrier Precautions (EBP) with appropriate Personal Protective Equipment (PPE) was not followed for 1 of 8 resident (R45) and lack of hand hygiene between glove changes during personal cares for 1 of 8 resident (R16). This was evidenced by: Example 1 The facility utilizes the Centers for Disease Control and Prevention (CDC) sign for EBP that states: Everyone must: .wear gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: urinary catheter . The facility policy, entitled Enhanced Barrier Precautions, revised 4/05/24, states: [...]

Inspectors wroteBased on observation and interview, the facility did not ensure the resident's right to personal privacy during a medical provider interview for 1 of 15 residents (R21). This is evidenced by: The facility policy entitled, Our Resident's Health Information is Confidential and on a Need to Know Basis reads in part, .protect resident's medical information from those who do not need to know the information . R21 was admitted to the facility on [DATE]. On 03/14/23 at 1:45 p.m., R21 along with eight other residents were attending the activity of hangman using a portable whiteboard led by Recreational Therapy Assistant (RTA) J. The activity was conducted in the Westview Lounge. Nurse Practitioner (NP) K came to get R21 from the activity and told the resident she needed to talk concerning medical information for a routine check in. [...]

Inspectors wroteBased on observations and interviews, the facility did not serve food in accordance with professional standards for food service safety. This has the potential to affect all 54 residents in the facility. Kitchen staff were observed changing gloves and not handwashing and touching ready to eat foods. Staff were observed opening straws for residents and touching the straw with their hands.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 2 of 14 (R33 and R49) residents reviewed for comprehensive care plans had a developed care plan specific to the resident. R33 had a diagnosis of dementia and did not have a comprehensive care plan to include dementia. R49's care plan included outdated information for bladder management and had not been updated to include R49's current plan of care. This is evidenced by: Example #1 On 3/14/23, Surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE] with a primary diagnosis of major depressive disorder. Other diagnoses included, but not limited to cognitive communication deficit and vascular dementia. Review of R33's Minimum Data Set (MDS) assessment, dated 01/05/23, included the diagnosis of non-Alzheimer's dementia. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure all staff who provide care to the residents were fully vaccinated for COVID-19. This had the potential to affect all 54 residents. Certified Nursing Assistant (CNA) M was not fully vaccinated for COVID-19 while working in the facility. CNA M did not have a temporary delay or exemption from receiving the COVID-19 vaccination.