Health inspection·September 19, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to implement physician orders for one of four sampled residents. (Resident 1) Residents Affected - Few Findings include: Clinical record review revealed that Resident 1 had diagnoses that included congestive heart failure (CHF), atrial fibrillation, hypertensive heart disease, and presence of a heart assistance device (cardiac implanted defibrillator). The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and required extensive assistance with hygiene and bed mobility. A review of the care plan revealed that the resident had cardiac disease related to the CHF, atrial fibrillation and use of an Left Ventricular Assist Device (LVAD). A LVAD is a surgically implanted device which helps the left ventricular main pumping chamber of the heart pump blood to the rest of the body. Review of current physician orders revealed that licensed staff was to check the settings on the LVAD and document the completion of the checks every shift. Staff was to document the LVAD pump speed, pump flow, pulsatility (a measure of the variance of blood flow velocity within the vessel throughout the cardiac cycle), and power in [NAME] each shift. There were parameters for each setting on the sheets for staff to verify if the settings were within the parameters to ensure that the LVAD was operating correctly. The LVAD was powered by re-chargeable batteries. Review of the documentation revealed that between August 1 and September 14, 2023, there was no evidence that staff documented the settings on August 13, 19, 27, 2023, on the 3:00 p.m.,-11:00 p.m., evening shift. There was no evidence that staff documented the settings on August 29, and September 6, 2023, on the 11:00 p.m., -7:00 a.m., night shift. There was no evidence that staff documented the settings on August 22, 2023, on the 7:00 a.m., -3:00 p.m., day shift. There was a total of six shifts where the staff failed to document the settings of the LVAD device as per the physician's order. In addition, there was a current physician order for staff to check the battery power and change the batteries one at at time every shift. Review of the Treatment Administration Record for September 2023, revealed that there was no documented evidence that staff checked the battery power on the 11:00 p.m., to 7:00 a.m. night shift on September 9 and 10, 2023. In an interview on September 19, 2023, at 1:00 p.m., RN1 confirmed that the batteries were to be changed by licensed nursing staff ( registered nurse's and licensed practical nurses) every shift and that only licensed nursing staff was to document the settings as per the physician's orders. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395429 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395429 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethlehem South Skilled Nursing and Rehabilitation 2021 Westgate Drive Bethlehem, PA 18017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)