Pruitthealth - Bethany

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and review of the facility policy titled Monitoring of Antipsychotics, the facility failed to monitor targeted behaviors for the use of an antidepressant medication for one of five residents reviewed for unnecessary medications (Resident (R )40) out of 23 sampled residents. This failure had the potential for residents to receive unnecessary medications. Findings include: Review of the facility's policy Monitoring of Antipsychotics with a revision date of 7/20/2020 and provided by the facility indicated, .Every patient/resident on a psychotropic medication will have an order for behavior monitoring in the EMAR [electronic medication administration record] system. This must be filled out by every nurse every shift and must spell out what behaviors have occurred on that shift . Review of R40's undated Face Sheet located under the Resident tab in the electronic medical record (EMR) indicated R40 was readmitted to the facility on [DATE] with the diagnosis of depressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of the facility policy titled Medication Administration: General Guidelines, the facility failed to ensure infection control was maintained for one of three residents (Resident (R) 20) observed during medication administration. Specifically, the facility failed to ensure that pills were not touched with bare hands or dropped during medication administration, which increased the risk for cross-contamination and infection. Findings include: Review of the facility policy titled, Medication Administration: General Guidelines dated 4/10/2019 provided by the facility indicated, .A clean spatula, razor blade, or knife is used to avoid contact with the tablet. During observation and interview of medication administration on 5/7/2025 from 9:00 am to 9:10 am, with Licensed Practical Nurse (LPN) 5, revealed LPN5 was opening multiple pill packs for R20 and pouring them into the pill cup when one of the pills missed the cup and ended up on the top of the medication cart. LPN5 picked up the unknown pill with a bare hand and placed it back into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, review of the facility policy titled, Antibiotic Stewardship Program, and review of McGeer's criteria, the facility failed to have an Antibiotic Stewardship Program that followed current standards of practice for prescribing an antibiotic for two of three residents (Resident (R)13 and R15) reviewed for antibiotic stewardship out of total sample of 23. This failure had the potential to cause residents to be prescribed antibiotics that were potentially unnecessary. Findings include: Review of the facility's policy Antibiotic Stewardship Program, with a revision date of 11/30/2023, and provided by the facility stated, . The antibiotic time out should be performed within 24-48 hours after antibiotics are initiated . The ASP [Antibiotic Stewardship Program] Team will monitor and review the following data: i. Infections and antibiotic usage patterns on a regular basis . v. Include a separate report for the number of residents on antibiotics that did not meet criteria for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, review of the facility policy titled, Pneumococcal Vaccinations, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer or provide documentation of consent or refusal for three of five residents (Residents (R)13, R40, and R60) and/or their resident representatives the opportunity for the residents to receive influenza and/or pneumonia vaccines out of 23 sample residents. This failure had the potential to put these residents at an increased risk of developing influenza and/or pneumonia. Findings include: Review of the facility's policy Pneumococcal Vaccinations dated 8/29/2023 and provided by the facility stated, . The admission process will include determining whether the patient/resident has received the pneumococcal vaccine in the past. This will be the responsibility of the Director of Health Services or designee. Every effort will be made to obtain documentation of the date of prior immunization and what type of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents' rooms and bathrooms were safe and maintained to promote a pleasant and homelike environment in 24 of 53 rooms (101, 102, 103, 104, 105, 106, 107, 108, 110, 112, 115, 117, 118, 119, 120, 121, 122, 123, 124, 126, 127, 128, 130 and 132) observed. Findings include: During an environmental tour of the facility on 09/28/23 at 9:45 am, the following maintenance items were observed: 1. Resident rooms 105, 106, 107,108, 110, 112, 121, 122, 123, 124, 126, 128, 130 and 132 had missing threshold strips on one or both sides of the entrance into the bathroom. The missing strip was between the tile floor and the laminate floor, which created an uneven surface going into and out of the bathroom. 2. Resident rooms 101, 103, 127 had missing baseboards. 3. The bathroom between resident rooms [ROOM NUMBERS] was observed to have an over the toilet assistive device in disrepair. All four legs were heavily coated with a rust-colored substance.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, record review, and a review of the facility policy titled, admission Orders, the facility failed to have a physician order for administering oxygen for one of two resident (R) (66) reviewed for oxygen and failed to have a physician order for the tracheostomy size and type for one of one (R81) resident reviewed for tracheostomy (a tube inside of the windpipe in the throat to allow for breathing) care. This placed R66 at risk for receiving too much or too little oxygen and placed R81 at risk of having respiratory issues related to the incorrect size or type of tracheostomy appliance. Findings include: Review of a facility policy titled admission Orders, dated September 2022, provided by the facility indicated, .Policy: At the time of admission to a healthcare center/agency, in order to assure quality patient/resident care and to comply with Federal law it is necessary that complete and accurate physician orders for the patient/resident's immediate care be obtained. 1. The orders must be reviewed by the admitting nurse and should at least address…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy, the facility failed to maintain oxygen equipment (including changing and dating oxygen tubing, cleaning oxygen concentrator filters, and storing nasal cannula tubing in clear bags) for three residents of four residents (Resident (R) 19, R43, and R47) reviewed for respiratory/oxygen therapy. Additionally, the facility failed to maintain emergency equipment for one resident of one resident (R7) with a tracheostomy. The deficient practice had potential to affect four of eleven residents receiving respiratory treatment by increasing respiratory germs exposure; cause R43 respiratory distress due to inaccurate oxygen flow rate; and the potential for the emergency tracheostomy kit to have outdated or missing supplies. Findings include: Review of the facility-provided policy titled Oxygen Administration, revised [DATE], revealed .Regulate liter flow to ordered/desired flow rate . O2 [oxygen] humidifier bottles should be used on all patients receiving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and review of facility policy, the facility failed to ensure proper consistency of the pureed meats for nine residents on pureed texture diets of 78 census residents. The deficient practice has the potential to create a choking risk and result in decreased resident intake. Findings include: Review of the facility's policy titled Pureed Texture undated, indicated The pureed texture provides foods with a semi-liquid to semi- solid consistency such as applesauce to mashed potatoes. The pureed texture consistency is normally that of applesauce or mashed potatoes. Some foods may be smooth, and some may have some texture but no lumps. During an observation of the main kitchen on 04/13/22 at 9:43 AM, the Dietary Manager (DM) said the Robot Coupe (motorized blender) was not working right now and they were having a hard time finding a replacement. They were using a small blender to puree the food. Dietary Aide (DA) 1 was observed pureeing diced chicken. DA1 placed some diced chicken in the blender along with some stock from the chicken. DA1 blended the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy, the facility failed to ensure one resident of 24 sampled residents (Resident (R) 14) had a physician's order and was screened/assessed for the self-administration of medications prior to medications being stored at the bedside and self-administered by the resident. The deficient practice created the potential for medication errors to occur. Findings include: Review of facility-provided policy titled, Self-Administration of Medications by Patient/Resident, revised 01/28/20, revealed .Each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient and other patients/residents of the healthcare center. medication self-administration also applies to family members who wish to administer medications. The opportunity to self-administer medications is reviewed during the routine assessment by the healthcare…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were encoded and transmitted for two of two residents (Resident (R) 1 and R2) reviewed for Resident Assessment. This failure creates a potential discrepancy or delay in benefits due to payor sources not notified of a resident's admission status. Findings include: 1. Review of R1's Face Sheet located in the electronic medical record (EMR) showed a facility admission date of [DATE] with medical diagnoses that included heart failure, hypertensive heart and chronic kidney disease, and end stage renal disease. Further review of the Face Sheet indicated the resident's status as Expired. Review of R1's Progress Notes located in the EMR revealed on [DATE] at 1:37 PM, the Nurses Note, indicated, [Local Hospital] center called to check on resident status. Was reported resident was transferred to [Regional Hospital]. Review of R1's MDS located in the EMR in the under the RAI Tab showed the following assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for one of one resident (Resident (R) 18) reviewed for nutritional status; resulting in continued significant weight loss. Findings include: Review of the facility's policy titled Patients/Residents at Nutritional Risk revised June 2016 indicated It is the policy of [facility name] for the in-house Registered Dietitian (RD) or Consulting Dietitian to routinely assess patients/residents at nutritional risk. Documentation must be completed at a minimum of quarterly and/or as needed based on change in enteral feedings, tolerance, changes with nutritional interventions, and/or significant weight loss. Review of R18's Face Sheet, undated, located in R18's electronic medical record (EMR) under the Face Sheet tab, indicated a current admission date to the facility of 09/10/21 and readmission on [DATE]. The Face Sheet indicated R18 had diagnoses of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.