Bethel Home

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R26 and R64) as well as staff, volunteers, visitors, and other individuals providing resident services. This practice had the potential to affect more than 4 of the 70 residents residing in the facility. The facility did not implement transmission-based precautions (TBP) for residents at the onset of respiratory symptoms to prevent the spread of contagious illness. R26 was not placed on droplet precautions at the onset of respiratory symptoms on 8/11/25. R26 was admitted to the hospital on [DATE] and diagnosed with sepsis due to pneumonia of right lower lobe due to infectious organism. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R44 and R3) of 2 sampled residents were accurately assessed for self-administration of medication. Theraworks pain relief spray was observed at R44's bedside. R44's most recent Self-Administration of Medication assessment, dated 9/3/25, indicated R44 was unable to self-administer medication. Oral medication and eye drops were observed at R3's bedside. A Self-Administration of Medication assessment for R3 was not thoroughly completed. In addition, R3 signed consent to self-administer medication while incapacitated.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R26 and R39) of 5 sampled residents were provided pneumococcal vaccines. R26 was eligible to receive a pneumococcal vaccine. The facility did not obtain R26's consent or declination to receive the vaccine in a timely manner. R39 was eligible for and signed consent to receive a pneumococcal vaccine. The facility did not administer the vaccine in a timely manner. Findings Include: The facility's Infection Control-Immunizations policy, revised 1/2025, indicates: The facility will ensure each resident is offered a pneumococcal immunization unless the immunization is medically contraindicated or the resident has already been immunized. The resident's medical record includes documentation that indicates, at a minimum, the following: [...]

Inspectors wroteBased on staff interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R1) of 5 sampled residents when staff used a mechanical lift without ensuring a safety latch was in place prior to transferring R1. On 7/30/25 at 11:00 AM, Certified Nursing Assistant (CNA)-C and CNA-D transferred R1 from bed to Broda chair via a Liko Golvo 7007ES full body lift. CNA-C and CNA-D positioned the sling under R1 and hooked all 4 sling loops onto 2 hooks on either end of the sling bar. During the transfer, a sling loop slid down the sling bar, which caused the bar to go vertical. A safety latch that should have been attached to the sling bar hook was missing which caused a sling loop to detach from the lift. CNA-C and CNA-D were aware the safety latch was missing prior to the transfer. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure the plan of care was revised for 1 resident (R) (R1) of 3 sampled residents. R1's plan of care was not updated to include recommendations from an Advanced Practice Nurse Prescriber (APNP) regarding transfer speed and hydration related to orthostatic hypotension (a condition where blood pressure drops when standing or sitting up) and unresponsive episodes.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a physician saw and responded to radiological records for 1 resident (R) (R1) of 3 sampled residents. R1 had X-rays of the shoulder and clavicle completed on 10/9/24 after R1 passed out during a transfer and complained of right shoulder/clavicle pain. R1's shoulder X-ray showed normal findings. R1's clavicle X-ray indicated R1 had a fracture. The facility did not ensure a physician received the results of R1's clavicle X-ray.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 Residents (R) (R50, R65 and R27) of 4 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. R50 was transferred to the hospital on 4/5/24, 6/5/24, and 7/28/24. Neither R50 or R50's emergency contact were provided with a written transfer notice for R50's hospital transfers. R65 was transferred to the hospital on 6/24/24. Neither R65 or R65's representative were provided with a written transfer notice for R65's hospital transfer. R27 was transferred to hospital on 6/24/24. Neither R27 or R27's representative were provided with a written transfer notice for R27's hospital transfer.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 Residents (R) (R50, R65, and R27) of 4 residents reviewed for hospitalization received the proper bed hold notice when transferred to the hospital. R50 was transferred to the hospital on 4/5/24 and 7/28/24. The facility did not provide R50 or R50's emergency contact with a bed hold notification. R65 was transferred to the hospital on 6/24/24. The facility did not provide R65 or R65's legal representative with a bed hold notification. R27 was transferred to the hospital on 6/24/24. The facility did not provide R27 or R27's legal representative with a bed hold notification. Findings Include: 1. Between 8/5/24 and 8/7/24, Surveyor reviewed R50's medical record. R50 was admitted to the facility on [DATE] with diagnoses including follicular lymphoma, chronic congestive heart failure, and type 2 diabetes. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R33) of 1 resident was transferred safely and according to their plan of care. R33 was transferred via mechanical lift without the use of the lower extremity safety strap and without therapy staff present.

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility did not ensure the accurate administration of medication for 1 Resident (R) (R33) of 1 resident reviewed. R33's medications were left at the bedside for R33 to self-administer. R33 did not have a physician's order or a self-administration of medication assessment that indicated R33 could safely and accurately self-administer medication.

Inspectors wroteBased on record review and staff interview, the facility did not ensure timely transmittal of Resident Assessment Information (RAI)/Minimum Data Set (MDS) assessments for 14 Residents (R) (R8, R47, R61, R51, R17, R42, R12, R9, R37, R25, R66, R16, R31 and R15) of 72 residents. The facility did not timely transmit RAI/MDS assessments for R8, R47, R61, R51, R17, R42, R12, R9, R37, R25, R66, R16, R31 and R15.