Bethel Lutheran Home

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program for 49 of 49 sampled residents when: 1. Licensed Vocational Nurse (LVN) 4 went into Resident 1's room, who was on contact precautions (requiring staff and visitors to wear gloves and gowns when entering the room, wash hands thoroughly, and use special equipment to prevent touching the patient or their stuff to stop germs from spreading from a sick person to others), and performed patient care without wearing personal protective equipment (PPE) such as a gown and gloves. This failure placed all residents LVN 4 came in contact with at risk for cross contamination (when harmful bacteria move from one item to another), of bacteria that could result in resident infections and illness. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmaceutical services kept accurate records for 23 out of 23 residents when 37 controlled substance medication (medication with a high potential for physical and mental dependence) entries, from 6/26/25-11/18/25, did not have a Registered Nurse witness signature for destruction on 11/20/25 in the controlled drug disposition log. This failure resulted in inadequate record keeping of controlled substance medication which had the potential to lead to inaccurate controlled medication inventory, diversion (when healthcare providers obtain or use prescription medicines illegally) of controlled medications and delayed identification of controlled medication diversion. During a concurrent interview and record review on 12/4/25 at 3:25 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately label and store medications in one of two medication carts and one of two medication rooms when:1. Medication cart, referred to as, medication cart B, contained one prescription medication with no expiration date for one resident (Resident 30)2. Medication room, referred to as, medication room C, contained one expired prescription medication for one resident (Resident 6). This failure had the potential to decrease medication potency that could compromise the therapeutic effectiveness of stored medications. During a concurrent observation and interview on 12/2/25 at 2:29 p.m. with Licensed Vocational Nurse (LVN) 3, medication cart B was observed behind nursing station B. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 19 of 49 residents receiving meals from the kitchen were served the correct serving for lunch on 12/3/25 when 19 residents on regular texture and portion diets were served sea greens with an incorrect serving size of #10 scoop (3/8 cup) instead of a #8 scoop (1/2 cup) serving. This failure resulted in 19 residents receiving the wrong caloric intake which could result in inadequate nutrition, weight gain or weight loss, and lead to serious medical conditions. During a review of the facility's document titled, Diet Type Report, dated 12/4/25, the document indicated 49 residents received meals from the kitchen. The document indicated 19 of 49 residents received regular texture diets with regular portions from the kitchen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food and beverages were stored, distributed, and served safely in accordance with professional standards of food service safety for 49 out of 49 residents eating at the facility when: 1. Three packages of bread were expired in the dry good pantry.2. Two opened cereal containers were not labeled with received, opened and expiration dates in the dry good pantry.3. One opened crushed rosemary seasoning was expired in the kitchen preparation area.4. One lemon juice bottle was stored below meat and had a wet, yellow spotted sticky substance on the bottle in the serving preparation fridge. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 15 residents (Resident 9), when Resident 9's care plan indicated she needed one on one (1:1- one dedicated caregiver gives their full, undivided attention to just that person) supervision and a bolster (a long pillow or cushion) mattress on her bed and neither of those interventions were being implemented. This failure of not implementing an individualized care plan for Resident 9 had the potential to place Resident 9's safety at risk and her specific needs not being met. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of practice for one of thirteen sampled residents during medication administration (Resident 6) when Resident 6's Tylenol (pain medication used to treat mild pain) medication lacked an appropriate indication and an associated pain rating scale to guide administration. This failure resulted in Resident 6's Tylenol medication order not having complete and appropriate administration instructions which resulted in the administration of Tylenol with no prior pain assessment which could lead to uncontrolled or mismanaged pain management. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that medical records were complete for one of seven sampled residents (Resident 64) when Resident 64's Inventory of Personal Effects form (An Inventory sheet of resident's personal belongings completed upon admission to the facility) was incompletely filled out. This failure had the potential to result in Resident 64's poor continuity of care due to miscommunication among caregivers, inconsistent care delivery or loss or theft of personal belongings. During an interview on 12/4/25 at 11:29 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated an Inventory of Personal Effects form is filled out on admission by the CNA, signed by the CNA, and the form given to the nurse. [...]

Inspectors wroteBased on interview and record review, the facility failed to have record of abuse in-service training for the year 2025 for one of three certified nursing assistants (CNA 4) reviewed. This failure had the potential to put all 49 residents at risk of experiencing abuse by staff. During a concurrent interview and record review on 12/4/25 at 10 a.m., with the Director of Staff Development/Infection Preventionist (DSD/IP) and Director of Nursing (DON), the abuse in-service training sign-in sheet (AIS) for employed certified nursing assistants (CNA) for 2025 was reviewed. The AIS indicated CNA 4 was not accounted for in having completed her abuse in-service for 2025. The DON stated CNA 4 was a full-time employee. During an interview on 12/5/25 at 2:51 p.m., with the DSD/IP she stated she was responsible for the abuse trainings but was not the DSD at the time of these trainings. [...]

Inspectors wroteBased on observation and staff interview during the survey period from 12/2/25 through 12/5/25, the facility failed to ensure each bedroom had 80 square feet of usable living space for residents in 22 of 29 rooms (Rooms 27, 28, 29, 31, 32, 33, 34, 35, 36, 47, 48, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59 and 60). This failure to provide the residents in rooms 27, 28, 29, 31, 32, 33, 34, 35, 36, 47, 48, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59 and 60 with 80 square feet (sq ft- unit of measurement) of space had the potential for the residents to not have enough space to accommodate their personal needs and belongings. During an interview on 12/2/25 at 10 a.m., with the Administrator (ADM), the ADM stated he was aware rooms 27, 28, 29, 31, 32, 33, 34, 35, 36, 47, 48, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59 and 60 did not meet the minimum space requirement for two residents. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care in a manner that maintained dignity and respect for one of three sampled residents (Resident 1), when Resident 1 was awoken at 2:00 a.m. and subjected to two attempted straight catheterizations (invasive thin flexible tube used to drain urine from the bladder) without a physician order or consent. This failure violated the resident's rights to receive care in a dignified and respectful manner. During a review of Resident 1's admission Record (AR) dated 8/22/25, the AR indicated, Resident 1 was initially admitted to the facility on [DATE] with diagnoses of hemiplegia (the loss of the ability to move one side of the body), Metabolic encephalopathy (brain dysfunction, which disrupts normal brain function) and malignant neoplasm of brain ( a cancerous growth in the brain or central nervous system). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician orders were followed for 1 of 3 sampled residents (Resident 1). When the Licensed Vocational Nurse (LVN) 1 obtained a urine specimen by straight catheterization (invasive thin flexible tube used to drain urine from the bladder) without a physician order for catheter. This failure had the potential to place the resident at risk for unnecessary pain, infection, and psychosocial harm. During a review of Resident 1's Order Summary Report (OSR) dated 8/8/25, at 1307 the OSR indicated, .May have UA (urinalysis medical test that examines urine to help diagnose medical conditions). One time only for foul order for 3 days. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the rights of two of three sampled residents (Resident 1 and Resident 2) right to a dignified private and personal space was respected when one facility male employee laid down on the bed with Resident 1 and had taken a nap with her for several minutes; and when Resident 1's roommate, Resident 2, observed this. This failure resulted in the potential for psychosocial harm such as emotional distress for Resident 1 and Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three employees' (CNA 1 and CNA 3) orientation to the facility and education documentation was thorough and completed by the Director of Staff Development (DSD). This failure had the potential for staff education requirements to not be verified by the DSD, enabling poorly trained staff to work in the facility with residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three employees ' (Certified Nursing Assistant, or CNA 1) education on Resident ' s Rights was thorough and completed by the Director of Staff Development (DSD). This failure resulted in staff education on Resident Rights to not be completed and verified by the DSD for CNA 1, enabling CNA 1 to be untrained on Resident Rights while working with residents, including Resident 1 [cross-reference with F550].

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards of practice for food service safety when: 1. A walk- in freezer had beef stew meat with ice crystals inside the bag labeled 7/14/24. 2. A foam cup containing food with staff name undated labeled was stored on shelf in walk-in refrigerator. 3. An open yogurt container with no opened date was found in the walk-in refrigerator 4. A white bin containing oats was not labeled with open and received date in the storage room. 5. Cookies, snacks and 2-liter sodas brought from family members, were found with no label of date opened, date received, or initials, in two of six sampled residents' (Resident 2 and 24) room. These failures had the potential to transmit food-borne illnesses to residents. 1. [...]

Inspectors wroteDuring observation, interview, and record review the facility failed to ensure privacy and confidentiality for two out of four residents (Resident 10 and Resident 15) during medication administration and medical treatment when: 1. Resident 10's curtains were not pulled during blood glucose testing (a measurement of the amount of sugar in a person's blood. It involves a finger prick or blood draw from the vein) and administration of insulin (a medication that lowers the amount of sugar in the blood). 2. Resident 15's curtains were not pulled during the administration of eye drops. These failures had the potential to place Resident 10 and Resident 15 at risk of losing their privacy and confidentiality during their medical treatments, and not attaining, or maintaining physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation interview and record review the facility failed to provide services that met professional standards of quality of care for one of six sampled residents (Resident 3) when Resident 3's Hoyer lift sling (a mobile device which helps caregivers safely transfer patients) was used incorrectly during a transfer from his wheelchair to the bed. This failure caused Resident 3 to experience pain and discomfort and had the potential to result in injury as a result of using the lift improperly.

Inspectors wroteDuring observation, interview, and record review, the facility failed to ensure accurate labeling of resident medications, and storage of resident medications at proper temperatures to preserve their integrity in accordance with accepted professional standards of practice when: 1. One of two medication carts had two out of 199 pill packets with no visible expiration dates. 2. Seven out of seven boxed medications did not have the inside medication container labeled with resident information. 3. One of two medication refrigerators was below the facility required temperature range of 36 degrees Fahrenheit (F) and 46 degrees F. These failures put residents at risk for unsafe administration of medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 56 of 56 sampled residents received safe and appetizing temperature food when Dietary [NAME] (DC) did not check temperature of food on steam table on 10/23/24 before serving. This failure had the potential for all 56 residents to be served cold food and for all 56 residents to contract food borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor and maintain essential equipment in a safe operating condition for one of two medication room refrigerators, when the refrigerator temperature reading was below the acceptable range for safe holding of medication. This failure had the potential to put residents whose medications were held in the B-wing medication refrigerator at risk of receiving unsafe and ineffective medications.

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan in regard to pain for one of one residents (Resident 3), when staff did not pre-medicate Resident 3 with an analgesic (a medication that reduces pain) prior to physical therapy. This failure to not follow the care plan, resulted in Resident 3 to have unmanaged pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the right to be free from pain for one of one residents (Resident 3), when Resident 3 was not given analgesia (pain medication), per his care plan, before physical therapy. This failure resulted in Resident 3 experiencing pain during a transfer from his wheelchair to his bed and during physical therapy.

Inspectors wroteBased on observations, interview, and record review the, the facility failed to ensure the physician order (set of instructions written by a doctor) was followed for one of the six sampled residents (Resident 14) was served an incorrect scoop size for small portion diet on 10/23/24. This failure had the potential for Resident 14 to received more than the recommended number of calories ordered by the physician.

Inspectors wroteBased on observation interview and record review the facility failed to ensure meal preferences were followed for one of seven residents (Resident 51) when Resident 51 was served items on her list of disliked foods of chicken with skin and beets. This failure had the potential to cause Resident 51 to experience inadequate nutrition and weight loss as a result of not eating.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards of practice for one of six sampled residents (Resident 8), when Resident 8's antipsychotic consent forms were incomplete. This failure put Resident 8 at risk of receiving antipsychotic medication prior to being informed of the risks and benefits of taking the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of infections for 56 of 56 sampled residents when Contractor Technician (CT) did not wash his hands upon entering kitchen. This failure had the potential to cause cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and foodborne illnesses to 56 residents, staffs and visitors that received ice from the ice-machine.

Inspectors wroteBased on observation, interview, and record review, during the survey period of 10/22/24 to 10/28/24, the facility failed to provide the minimum of at least 80 square feet per resident in multiple resident rooms (Rooms 27, 28, 29, 31, 32, 33, 34, 35, 36, 47, 48, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59 and 60). This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility medication error rate did not exceed five percent (eight percent) when: 1. Licensed Vocational Nurse (LVN) 5, administered Resident 5's (brand name) calcium tablet (used to prevent or treat low blood calcium levels in people who do not get enough calcium from their diets.) with vitamin D (nutrient the body needs for building and maintaining healthy bones) for an order of (brand name) Calcium 500 mg. This failure had the potential for Resident 5's Vitamin D level to go higher and lead to serious medical condition. 2. LVN 2 administered Resident 30's Multivitamin (used to treat or prevent vitamin deficiency due to poor diet, certain illnesses or during pregnancy) gummies (chewy gelatin-based) for an order of multivitamins-minerals. [...]

Inspectors wroteDuring a review of Resident 26's admission Record (AR), (undated), the AR indicated, . Resident 26 was admitted to the facility on [DATE] . During a review of Resident 26's paper chart the Physician Orders for Life-Sustaining Treatment (POLST), dated [DATE], the POLST indicated, Resident 26 did not have an advanced directive. Resident 26's Health Care Power of Attorney Appointment of Health Care Agent and Proxy document dated [DATE] was located in Resident 26's paper chart. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident was treated with dignity and respect for one of four sampled residents (Resident 5) when Licensed Vocational Nurse (LVN) 5 administered medication to Resident 5 in the hallway. This failure resulted in Resident 5 not being provided with respect and dignity while taking her medications.

Inspectors wroteBased on interview and record review, the facility failed to provide access to personal funds for one of two sampled residents (Resident 10) when he was unable to request his personal funds on the weekends. This failure resulted in Resident 10 not being able to access his funds on the weekends for his personal needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide residents with accessibility to file a grievance, anonymous grievance or complaint and did not update the grievance policy to ensure the prompt resolution of grievances for seven of ten sampled residents (Resident 25, Resident 10, Resident 17, Resident 18, Resident 19 and Resident 48, Resident 37) when: 1. Resident 37 filed a grievance in September 2023 requesting a room change and the grievance was not documented and followed up on by the facility staff. 2. Resident 25, Resident 10, Resident 17, Resident 18, Resident 19 and Resident 48 did not know how to file a grievance anonymously. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS-a resident assessment tool used to identify resident care needs) assessment accurately reflected the residents' current status for one of six sampled residents (Resident 19) when Resident 19's MDS assessment of Health Conditions (Section J) was not coded accurately. This failure placed Resident 19's at a potential of her smoking needs to be not met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive, person-centered care plan (A plan that provides direction for individualized care of the resident) was developed and implemented to meet the needs for two of five sampled residents (Resident 47, Resident 7) when: 1. Resident 47 did not have a care plan for activities. This failure had the potential to result in Resident 47's activities to go unmet and could result to self isolation. 2. Resident 7 did not have a care plan for milk allergy. This failure had the potential for Resident 7 to receive milk products which could result in breathing difficulty or other health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of practice for one of six sampled residents (Resident 46) when Licensed Vocational Nurse (LVN) 4 left Resident 46's morning medication at bedside accessible to others. This failure placed Resident 46 at risk for not taking the medications, medication error, other residents or unauthorized personnel to access Resident 46's medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications (medications which affect the mind, emotions, and behavior) for one of four residents (Resident 34) when Resident 34 was given divalproex (an anticonvulsant medication used to treat seizures [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness]) without consistent indication for use, documented non-pharmacological interventions, and clinical justification to support the use of divalproex. This failure resulted in Resident 34 receiving unnecessary psychotropic medications and placed the Resident 34 at an increased risk for developing adverse (harmful) side effects due to taking divalproex.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications used were labeled and stored in accordance with professional standards when: 1. Resident 5's (linaclotide brand name - medication used to treat constipation) medication label did not match the medication order. This failure had the potential for the medication not to be administered according to the physician's order and resident's need. 2. A medication cart in B-wing unit was left unlocked and unattended by Licensed Vocational Nurse (LVN) 5. This failure placed all residents' health and safety at risk when drugs were left unattended and accessible to unauthorized individuals. 3. A bottle of over the counter (OTC) medication was left on top of the medication cart, unattended by LVN 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage was properly contained in dumpsters (garbage containers) covered with lids for one of five dumpsters when one garbage dumpsters outside of the facility was left uncovered, with lids to the side. This failure had the potential to attract rodents, insects and flies and spread infection placing residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of infections when: 1. One of three sampled resident's (Resident 4) foley catheter (indwelling urinary catheter - a thin tube placed in the bladder to drain urine into a bag) tubing was lying the floor on two separate occasions. This failure placed Resident 4 at risk for catheter contamination and a urinary tract infection (UTI- an infection in any part of the urinary system [kidneys, ureters, bladder]). 2. Two of two non-kitchen staff (staff position unknown and Maintenance Director [MS])entered the kitchen area without wearing proper hair covering and washing their hands. [...]

Inspectors wroteBased on observation, interview and record review, during the survey period of 11/27/2023 to 12/1/23, the facility failed to provide the minimum of at least 80 square feet per resident in multiple resident rooms (Rooms 27, 28, 29, 31, 32, 33, 34, 35, 36, 47, 48, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59 and 60). This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered.