Bethel Lutheran Home, Inc.

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.

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.

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.

Based on records reviewed and interviews conducted, R1 went to the hospital on 01/12/25, R2 went to the hospital on 02/25/25 and on 03/03/25, and R3 went to the hospital on 01/04/25. No records of incident reported to the department of residents’ hospitalization, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Based on observations and records reviewed, R5’s medication Premarin Vag w/ App 0.625mg was administered and record in the resident’s MAR, which poses/ posed a potential health and safety risk for the person in care.

Based on interview conducted, observation, and records reviewed, R1 and R4 uses half rail bed with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Based on observation, bathroom sink was linking water in Room 13, which poses/ posed a potential health and safety risk to the resident in care.

Administrator is not associated to facility which poses an immediate risk to the health and safety of the residents

Based on observation, the licensee did not comply with the section cited above when LPA and LVN observed prescribed medication stored in R1’s bathroom. LPA audit R1’s medication and review MARS and one of R1’s medication was not stored in the facility which poses an immediate health, safety or personal rights risk to person in care.

S1 is not associated to facility which poses an immediate risk to the health and safety of the residents. .

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.

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.

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.