Bethel Manor

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents privacy. Staff did not knock on resident doors before entering to deliver meal trays. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER])

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food under sanitary conditions during 3 of 3 kitchen observations. Food was not labeled correctly, expired food was not disposed of, hairnets were not worn properly, and staff placed their fingers in their mouth during food service. (Main Kitchen, Cottage Kitchen, Dietary [NAME] 9)

Inspectors wroteBased on record review and interview, the facility failed to develop a plan of care related to recurrent urinary tract infections (UTIs), or medication used to treat recurrent UTIs, for 1 of 1 resident reviewed for UTIs. (Resident 3)

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were revised after a fall for 3 of 6 residents reviewed for falls. (Resident 7, Resident 54, Resident 3)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was correctly prepared during 1 of 1 observation of puree altered diet preparation. (Dietary [NAME] 9)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control practices and standards were performed during 2 of 2 random observations. Staff did not use Personal Protective Equipment (PPE) for a resident on Enhanced Barrier Protection (EBP) and did not clean blood pressure equipment between residents. (Resident 2, Resident 63, and Resident 64)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety for 2 of 2 observations of the kitchen. Floors and equipment were soiled. (Kitchen) On 3/4/25 at 9:30 a.m., the kitchen was observed to have the following: 1. The burners on the stove had grease and food build up. 2. Debris was observed on the floor under the two and three compartment sinks, under the racks that held the pots and pans, under stainless steel prep tables, in the dishwasher area, around the hot water heater, under the stove and steam table. 3. The hot water heater had dirt/dust on the top of heater and on the pipes. 4. Five food carts had debris on the surfaces. 5. The side of the steamer unit had debris. The same was observed on 3/5/25 at 11:05 a.m. On 3/5/25 at 11:07 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents requiring assistance with Activities of Daily Living (ADLs) received adequate assistance with showering/bathing for 4 of 4 residents reviewed for dependent ADL care. (Resident 28, Resident 37, Resident 57, Resident 6)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with limited range of motion or mobility received services to maintain or improve mobility for 4 of 4 residents reviewed for restorative therapy. (Resident 6, Resident 28, Resident 52, Resident 55)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dishwasher temperatures and chemicals were within range and logs were completed for 1 of 2 kitchens observed. (Cottage kitchen)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for 3 of 3 residents reviewed for transmission based precautions, and failed to position fans to prevent cross contamination in the laundry processing area for 1 of 2 random observations of the laundry room. (Resident 57, Resident 60, Resident 17, and Laundry Room)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 2 of 2 residents observed with medications at bedside (Resident 49, Resident 23)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident privacy for 2 of 2 random observations. Resident information was left visible on a computer screen during medication administration. (Resident 13, Resident 16)

Inspectors wroteBased on observations, interview, and record review the facility failed to protect the resident's rights to be free from physical abuse for 1 of 1 residents reviewed. Resident 36 was hit by CNA(Certified Nurse Aide) while receiving care resulting in laceration above the left eye. (Resident 36)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received necessary care and services upon admission for 1 of 3 residents reviewed for skin impairment. A resident who was admitted with skin impairment did not have treatment orders put in place upon admission. (Resident 101)

Inspectors wroteBased on record review and interview, the facility failed to ensure person-centered care plans were developed and implemented for 2 of 5 residents reviewed for unnecessary medications and behaviors. (Resident 37, Resident 49)

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 5 residents reviewed for unnecessary medications. A resident was given the wrong medication resulting in rebound congestion when the medication was discontinued. (Resident 56)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prevention of pressure ulcers for 2 of 3 residents reviewed for pressure injury. Interventions were not followed, and wound assessments were not completed as ordered. (Resident 54, Resident 55)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision and assistance to prevent accidents for 3 of 3 residents reviewed for falls. Interventions were not updated following falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen equipment was properly labeled and oxygen services were provided according to physician order for 1 of 1 reviewed for respiratory care. (Resident 24)

Inspectors wroteBased on record review and interview, the facility failed to ensure proper interventions were in place for monitoring symptom, side effects, and behaviors of medications for 2 of 2 residents reviewed for dementia. (Resident 46, Resident 37)

Inspectors wroteBased on interview and record review, the facility failed to ensure routine medications were available and dispensed according to physician's orders for 1 of 6 residents reviewed for medication administration. (Resident 28)

Inspectors wroteBased on record review and interview the facility failed to ensure a resident was free from unnecessary medications for 1 of 1 residents reviewed for hospice. A resident's as needed anti-anxiety medication was ordered for more than 14 days. (Resident 49)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to physician's orders and professional standards for 2 of 26 opportunities, resulting in a medication administration error rate of 7.69%. (Resident 53 and Resident 23)

Inspectors wroteBased on interview and record review, the facility failed to obtain consent before administering influenza vaccines for 2 of 5 residents reviewed for immunizations. (Resident 37 and Resident 36)

Inspectors wroteBased on observation, interview, and record review, the facility failed to post accurate actual hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift daily for 5 of 6 days during the annual survey period.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who required restorative nursing services received services for 7 of 8 residents reviewed. (Resident B, Resident C, Resident E, Resident F, Resident G, Resident H, Resident J)

Inspectors wroteBased on interviews, and record review, the facility failed to ensure residents environment remained free from accident hazards for 2 of 4 residents reviewed for falls. New interventions were not implemented following falls. (Resident H, Resident 5)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services of a RN (Registered Nurse) were available at least 8 consecutive hours a day, 7 days a week for 2 of 7 days reviewed for nurse staffing.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 1 residents reviewed for hospice. A resident's as needed anti-anxiety medication was ordered for greater than 14 days. (Resident 46)

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure deteriorated medications carts were disposed of for 2 of 4 medication carts. Loose pills were found in the bottom of the medication cart drawers. (North Hall, South Hall)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the posted nurse staffing sheets included the facility census and actual hours worked for 5 of 5 days during the survey.