Bethel Home

Inspectors wroteThe facility had a census of 50 residents and the sample included 14 residents. Based on observation, record review, and interview, the facility failed to revise the fall care plan with an appropriate intervention for two residents. Resident (R) R33 and R36. Additionally, the facility failed to update care plan with facility acquired pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for R2, and R23's care plan was not updated with psychotropic (alters mood or thought) medications changes. These deficient practices had the potential to have a negative effect on the overall physical and psychosocial well-being of the residents in the facility.

Inspectors wroteThe facility had a census of 50 residents and the sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards for four residents. Resident (R) 37 who had medications located in her room that was not secured. Additionally, three residents R21, R33, and R36 had repeated falls with inappropriate or lacked a care plan revision after falls. These failures placed the affected residents at risk for preventable accidents and related injuries.

Inspectors wroteThe facility reported a census of 50 residents. The sample included 14 residents reviewed for person-centered care plan development. Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan for three residents, Resident (R) 33 related to psychotropic (any class of medications that alter mood or thought) medication use and dementia (a progressive mental disorder characterized by failing memory, confusion) care. R21's care plan lacked interventions related to as needed (PRN) oxygen use and scheduled nebulized (a device which changes liquid medication into a mist easily inhaled into the lungs) medication use. [...]

Inspectors wroteThe facility identified a census of 50 residents with 14 residents sampled, which included one resident reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, interviews, and record review, the facility failed to perform an ongoing assessment of a stage three (full thickness pressure injury extending through the skin into the tissue below) facility acquired pressure ulcer for Resident (R) 2.

Inspectors wroteThe facility reported a census of 50 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure Resident (R)46's as needed (PRN) psychotropic (any class of medications that alters mood or thought) medication had the required 14 day stop date or clinical rationale for continued use beyond the initial 14 days. This deficient practice had the potential to lead to the resident receiving unnecessary psychotropic medications. Findings Included: - R46's Electronic Health Record (EHR) revealed diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (inability to sleep), and hypertension (elevated blood pressure). [...]

Inspectors wroteThe facility reported a census of 50 residents. Based on observations, interviews, and record review, staff failed to complete proper hand hygiend during wound care for Resident (R)2 and R21, to ensure best practice regarding infection control and prevention.

Inspectors wroteThe facility reported a census of 50 residents. Based on interview and record review the facility failed to ensure an effective and ongoing antibiotic stewardship for appropriate antibiotic use for the residents of the facility to prevent antibiotic resistance and the spread of multi-drug resistant organisms

Inspectors wroteThe facility census totaled 54, with 4 sampled for pressure injuries. Based on observation, interview, and record review the facility failed to establish and maintain a system to identify, track, and measure wounds when Residents (R) 51 admitted to the facility with two pressure injuries (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and had multiple wounds develop with no measurements, description, or follow up documented in the resident's record. [...]

Inspectors wroteThe facility reported a census of 54 residents. Based on observations, interviews, and record review the facility failed to ensure the competency of Licensed Nurses in the facility regarding wound/skin issues of residents to include the monitoring, measuring, identifying of skin issues and pressure injuries (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This deficient practice placed any resident with potential skin issues, at risk of worsening and further development of skin related injuries. (See F610, F655, F684, F686)

Inspectors wroteThe facility reported a census of 54 residents. Based on observation, interview, and record review the facility failed to ensure the QAPI committee developed and implemented timely action plans to address the quality deficiencies as identified in the annual health resurvey. This failure placed all resident with actual and/or potential skin integrity issues at risk.

Inspectors wroteThe facility census totaled 54, with one resident sampled for an injury of unknown origin. Based on observation, interview, and record review the facility failed to initiate an investigation, when Resident (R) 51 sustained bruising to his left wrist, right forearm, and a skin tear to the back of his right hand with no documentation or follow to determine the origin of the resident's injuries. The facility further failed to place interventions/protections, to ensure the resident did not sustain further injuries.

Inspectors wroteThe facility census totaled 54, with 4 sampled for pressure injuries. Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for Resident (R) 54, which included instructions needed to provide effective and person-centered care of the resident and met professional standards of quality care, when the resident developed a deep tissue injury to the left heel with no documentation or interventions in place on the resident's baseline care plan.

Inspectors wroteThe facility census totaled 54, with one resident sampled for non-pressure related skin conditions. Based on observation, interview, and record review the facility failed to identify, document, track, and measure skin issues when Resident (R) 23 had multiple skin tears, bruising and surgical removal of a cancerous lesion on the ear and had no measurements, description or follow up documented in the R23's record.

Inspectors wroteThe facility reported a census of 52 residents, with 11 included in the sample, and five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure adequate monitoring of insulin (a hormone produced in the pancreas) when staff failed to report out of parameter blood glucose (main sugar that the body makes from the food in the diet) levels for Resident (R) 45, per physician's orders.