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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 this date, Licensing Program Analyst (LPA) M. Yang conducted initial complaint investigation. LPA introduce self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with Nursing Home Administrator Jasdeep Dhariwal who stated Administrator Benjamin Carter is unavailable to attend meeting. LPA discussed complaint and delivered complaint findings to Nursing Home Administrator. During the course of the investigation, the facility was toured, records were reviewed, and interviews were conducted. All staff files providing care and supervision for residents, were reviewed and was observed to have no training records in the file. Nursing Home Administrator confirmed staff have no training records on file. Based on interviews conducted and records reviewed, the preponderance of evidences has been met. Therefore, the above allegation is found to be SUBSTANTIATED. An exit interview was conducted. A copy of this report and appeal rights were provided to Nursing Home Administrator whose signature on this form confirms receipt of this report.

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.

  • 1569.39(b)Type B

    1569.39(b) A residential care facility for the elderly that accepts or retains residents with restricted health conditions, as defined by the department, shall ensure that residents receive medical care as prescribed by the resident’s physician and contained in the resident’s service plan by appropriately skilled professionals acting within their scope of practice. An appropriately skilled professional may not be required when the resident is providing self-care, as defined by the department, and there is documentation in the resident’s service plan that the resident is capable of providing self-care.This requirement is not met as evidenced by: Based on record reviews, the licensee did not comply with the section cited above R1 and R1’s files were reviewed. R1 and R2’s who are diabetes with doctor’s order for insulin medication have no Restricted Health Condition care plan on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

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  • 87633(b)Type B

    87633(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident…This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when LPA reviewed R3’s file, whose currently receiving hospice care with no hospice care plan on file, which poses a potential health or personal rights risk to persons in care.

  • 87412(c)(2)Type B

    87412 (c)(2) Documentation of staff training.This requirement is not met as evidenced by: Based on record review and interview conducted, the licensee did not comply with the section cited above when all staff files did not have the proper documentation and required trainings, which poses/posed a potential health, safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the November 25, 2025 inspection of BETHEL LUTHERAN HOME, INC.?

This was a complaint inspection of BETHEL LUTHERAN HOME, INC. on November 25, 2025. 1 citation were issued: 1 Type B.

Were any citations issued to BETHEL LUTHERAN HOME, INC. on November 25, 2025?

Yes, 1 citation was issued (0 Type A, 1 Type B). The first citation was for: "1569.39(b) A residential care facility for the elderly that accepts or retains residents with restricted health conditio..."

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.