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Inspection visit

complaint

BETHEL LUTHERAN HOME, INC.License 1004000431 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

On 1/28/2023 Licensing Program Analyst (LPA) M. Garza arrived at facility for an unannounced complaint visit to deliver findings. LPA met by receptionist. Administrator was contacted but unavailable. LPA was given permission to meet with Director of Nursing (DON), Sam Parvinder. LPA was COVID pre-screened at entry. LPA completed a Health and Safety check on residents in care. Residents observed in hallway and in rooms at time of visit. During investigation LPA requested and reviewed documentation (resident roster, staff roster and contact information, visitor log for one month, house rules and a copy of daily schedule for residents). LPA observed a sign on the door with visiting hours (10-4) and “must call to schedule appointment”. Interviews conducted with staff support the allegation. The allegation listed above has met the preponderance of evidence standard per Title 22 and is found to be SUBSTANTIATED. Deficiencies cited on 9099D. Exit interview completed with DON, Sam. A copy of this report and appeal rights given.

Citations

3 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87468.1(a)(6)Type B

    87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night... This requirement was not met by LPA observation of front door being locked on 12/16/2022 and 1/28/23 during visits to facility not allowing residents to leave and return freely. This poses a personal rights, health and/or safety risk to residents in care.

  • 87705(f)(2)Type B

    87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidence by LPA observation of janitor closet being unlocked with chemicals accessible to residents in care. This poses a potential personal rights, health and/or safety risk to resident in care.

  • 87468.1(a)(11)Type B

    87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidence by: LPA observation and interviews completed. LPA observed sign on front door which stated visits were to be scheduled and between the hours of 10 am and 4 pm. This poses a potential personal rights, health and/or safety risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the January 28, 2023 inspection of BETHEL LUTHERAN HOME, INC.?

This was a complaint inspection of BETHEL LUTHERAN HOME, INC. on January 28, 2023. 1 citation were issued: 1 Type B.

Were any citations issued to BETHEL LUTHERAN HOME, INC. on January 28, 2023?

Yes, 1 citation was issued (0 Type A, 1 Type B). The first citation was for: "87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly ..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.