Bethel Pointe Health And Rehab

Based on observation, interview, and record review, the facility failed to ensure a staff member spoke to a resident in a dignified and respectful manner for 1 of 5 residents observed during medication administration. (QMA 15 and Resident E) Findings include:During a medication observation, on 6/17/26 at 11:52 a.m., QMA 15 prepared medication for Resident E and entered the resident's room. Resident E sat in her wheelchair, holding baby doll. QMA 15 approached the resident with the medication and indicated she had her medicine and asked the resident if she wanted to show how big of a girl she was by taking her medication. QMA 15 attempted to administer the resident's medication and the resident pulled back. QMA 15 attempted again, and the resident took the spoon. QMA 15 guided the resident's hand holding the spoon to her mouth. After the resident took the medication QMA 15 stated Look at her, she's a big girl, good job.During an interview, on 6/17/26 at 12:04 p.m., QMA 15 indicated she spoke to the resident in a childlike manner because that was how the resident responded. During an…

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, interview and record review, the facility failed to ensure medications were administered according to facility policy to prevent medication errors and failed to ensure medications were prepared and administered according to physician orders and facility policy for oral and inhaled medications. (Residents C, B, F, and E) Findings include:1.A 5/23/26 anonymous intake submitted to the Indiana Department of Health (IDOH) indicated a resident had been administered medications intended for another resident, resulting in hospitalization.Resident C's clinical record was reviewed on 6/17/26 at 10:28 a.m. Diagnoses included essential (primary) hypertension, acute on chronic diastolic (congestive) heart failure, obstructive and reflux uropathy, and dizziness and giddiness.His medications included buspirone (treat anxiety) 5 mg, paroxetine (treat depression) 40 mg, quetiapine (antipsychotic) 12.5 mg, and tramadol (opiate pain medication) 100 mg.A progress note, dated 5/22/26 at 10:32 p.m., indicated Resident C was administered baclofen (muscle relaxer) 10 mg, melatonin…

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 record reviews, the facility failed to ensure a medication cart was not left unlocked and unattended for 2 of 5 medication administration observations (North Medication Cart) and medication was not left unattended on top of a medication cart for 2 of 5 medication administration observations. (Center Medication Cart) Findings include:1. On 6/17/26 at 11:52 a.m., QMA 15 prepared medication for Resident E. She walked down the hall and administered the medication in the resident's room while leaving the North Hall medication cart unlocked and unattended at the nurse's station.At 12:04 p.m., QMA 15 returned to the unlocked cart. During an observation, accompanied by QMA 15, the medication cart contained eye drops, prefilled insulin pens, insulin needles, lancets, prepackaged medication, nebulizer vials, nose spray, antacid medication, liquid and powdered medication. During the observation, QMA 15 indicated that she normally locked the cart when she walked away from it but she was nervous and accidentally forgot to lock it.2. On 6/18/26 at 9:30 a.m.,…

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 obtain a physician's order for wound treatment in a timely manner and failed to implement physician's orders promptly to promote healing of a diabetic ulcer for 1 of 3 residents reviewed for skin conditions. (Resident 5) Findings include: Resident 5's clinical record was reviewed on 2/11/26 at 11:00 a.m. Diagnoses included primary hypertension, type 2 diabetes mellitus, and generalized muscle weakness.A current, 1/13/26, pressure ulcer care plan indicated Resident 5 had a stage 3 (full-thickness pressure injury) wound to the right lateral foot. Interventions included the following: treatment as ordered (1/13/26), report signs/symptoms of infection such as increased redness, warmth, induration at or near wound edges, foul odorous drainage (1/13/26), and initiate pain care plan interventions (1/13/26).A 1/21/26, admission, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired and had a stage 3 pressure…

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, interview, and record review, the facility failed to follow enhanced barrier precautions (EBP) during high contact care activities for a resident with an indwelling medical device for 1 of 4 residents reviewed for EBP. (Resident 47) Findings include:Resident 47's clinical record was reviewed on 2/11/26 at 3:19 p.m. Diagnoses included presence of left artificial knee joint, infection and inflammatory reaction due to internal left knee prosthesis, and disruption of external operation (surgical) wound.Current physician's orders included: Enhance Barrier Precautions (EBP) due to PICC (peripherally inserted central catheter) line and history of MRSA/VRE (Methicillin-Resistant Staphylococcus Aureus/Vancomycin-Resistant Enterococci) (antibiotic resistant bacteria), daptomycin (antibiotic) 500 milligram one time a day for knee joint infection, and non-weight bearing to left lower extremity.A current care plan, revised on 2/9/26, included the following: I require enhanced barrier precautions related to PICC line and history of MRSA/VRE. Interventions included: Staff…

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 record review and interview, the facility failed to provide/offer showers according to the resident's preferences to maintain proper hygiene for 1 of 3 residents reviewed for activities of daily living. (Resident B)Finding includes: Resident B's closed clinical record was reviewed on 1/22/26 at 11:16 a.m. The resident discharged from the facility on 1/7/26. Diagnoses included major depressive disorder, syncope and collapse, general muscle weakness, difficulty in walking, other abnormalities of gait and mobility, and a history of falling.An 11/11/25, admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. He used a walker and wheelchair for mobility. The resident required substantial staff assistance for lower body dressing, footwear donning, bathing, and shower transfers. He was dependent on staff assistance for toileting hygiene. Resident B required partial staff assistance to stand and transfer to the toilet. He occasionally had incontinence of urine. The resident…

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 interview and record review, the facility failed to provide services for a resident with a feeding tube to prevent complications for 1 of 1 resident reviewed for tube feeding. (Resident 47) Finding includes: During an interview on 3/17/25 at 4:02 p.m., Resident 47 indicated she had a feeding tube as a result of a stroke. She recently began to have a pureed diet with thickened liquids for nutrition. She continued to receive her medications every day through her feeding tube. Resident 47's clinical record was reviewed on 3/18/25 at 2:29 p.m. Diagnoses included cerebral infarction without residual deficits, gastrostomy status, dysphasia, pharyngoesophageal phase, moderate protein-calorie malnutrition, and generalized muscle weakness. A current physician order, dated 2/20/25, indicated to change the enteral tube for splits/cracks in the tube, plugged, and/or dislodgement as needed. The clinical record lacked orders for gastrostomy tube site care. An admission Minimum Data Set (MDS) assessment, dated 2/25/25, indicated the resident was cognitively intact. The resident required…

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 and interview, the facility failed to ensure insulin (a medication to treat diabetes mellitus) vials and pens were dated when opened and disposed of when expired for 2 of 5 carts reviewed for medication storage. (East and Center hall carts) Finding includes: 1. During a medication storage observation of the East hall cart, accompanied by RN 4 on [DATE] at 10:58 a.m., the following was observed: One open vial of Glargine (long-acting) insulin, undated; the vial contained approximately 90 units, and One open vial of Lispro (short-acting) insulin, dated [DATE], [DATE] and [DATE]; the vial contained approximately 80 units. During an interview at the time of the observation, RN 4 indicated the East hall cart provided medications for eight diabetic residents, and insulin was good for 28 days from opening. During an interview, at the time of the observation, the DON indicated the insulin with three dates was misdated and if the staff were unsure of the open date on insulin, it would need to be…

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 record review and interview, the facility failed to complete ordered wound treatments and assessments for 2 of 3 residents reviewed for wound care. (Residents B and C) Findings include: 1. The clinical record for Resident B was reviewed on 9/4/24 at 10:34 a.m. Diagnoses include multiple sclerosis, dementia, malnutrition, and type II diabetes. A current physician's order, dated 7/2/24, indicated to cleanse the area on the right shin with wound wash and pat dry. Apply wound gel to the wound bed and cover with gauze. Change daily and as needed if soiled or dislodged. A review of the electronic treatment administration record (eTAR) lacked documentation of the treatment being completed on 7/4/24, 7/11/24 to 7/14/24, and on 7/18/24. A current physician's order, dated 6/26/24 and discontinued 7/27/24, indicated to cleanse the right heel with wound wash and pat dry. Apply hydrogel to wound bed and cover with an abdominal pad and secure with gauze wrap. Change daily and as needed. A review of the eTAR lacked documentation of treatment being completed on 7/4/24, 7/11/24, 7/12/24,…

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, interview and record review, the facility failed to ensure medications were stored securely and disposed of according to policy and compliance regulations. (Residents E, F, G, H, J, K, L, M, N, O, P, Q, R, S, T, and U) Findings include: On 7/11/24 at 11:09 a.m., during an observation of the Wound Nurse's office with the Administrator present, a small, unlocked two-drawer file cabinet was located behind the desk and contained the following: Twenty-four tablets of ondansetron (antiemetic) 4 mg for Resident E with an order date 6/19/24. The resident still resided in the facility. Eleven capsule of hydroxyzine pamoate (antihistamine) 25 mg for Resident F, who discharged from the facility on 1/26/24. There were the following medications for Resident G: seven finasteride (prostate medication) 5 mg tablets, six Floranex (supplement) tablets, seven lisinopril (anti-hypertensive) 10 mg tablets, six pioglitazone HCL(diabetic) 15 mg tablet, nine atorvastatin calcium (cholesterol reduction) 20 mg tablets, thirteen methazolamide (anti-glaucoma) 25 mg oral tablets, seven…

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 an apical pulse was obtained prior to the administration of digoxin for 1 of 8 residents observed during medication administration (Resident 58). Finding includes: During a medication administration observation, on 6/6/24 at 8:33 a.m., RN 3 checked Resident 58's medications with the medication administration record. She opened plastic packages containing the medications. This included aspirin 81 mg, a multivitamin, cetirizine 5 mg (allergy symptoms), digoxin 125 mcg (micrograms) (heart failure/irregular heart rhythm), Eliquis 2.5 mg (blood thinner), Floranex (probiotic), furosemide 20 mg (diuretic), hydrochlorothiazide (blood pressure/diuretic), losartan 25 mg (blood pressure), metoprolol succinate extended release 100 mg (blood pressure/heart failure), potassium extended release 10 mEq (milliequivalents), and vitamin D3 50 mcg, and placed them in a medication cup. She took the medication cup and a Trelegy Ellipta inhaler 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.

Based on observation, interview, and record review, the facility failed to provide monitoring of a pressure injury and to develop and implement interventions to promote the healing of a pressure injury for 1 of 3 residents reviewed for pressure injuries (Resident C). Findings include: During an observation, on 6/4/24 at 10:12 a.m., Resident C was lying on her right side on a low air loss mattress at a 30-degree angle. During an observation, on 6/5/24 at 12:29 p.m., the resident was sitting up in bed. During an observation, on 6/6/24 at 3:34 p.m., the resident was lying on her right side on a low air loss mattress. Resident C's clinical record was reviewed on 6/4/24 at 3:57 p.m. Her diagnoses included age-related debility, disorientation, cauda equina syndrome, unspecified dementia unspecified severity with psychotic disturbance, chronic right heart failure, chronic kidney disease, and unspecified severe protein-calorie malnutrition. Current physician's orders included Allevyn adhesive external pad (wound dressing) - apply to left buttock topically every day shift (4/19/24) and…

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, interview, and record review, the facility failed to ensure an indwelling catheter and tubing was positioned properly to avoid contamination for 1 of 1 residents reviewed with urinary catheter (Resident C). Finding includes: During an observation, on 6/4/24 at 10:12 a.m., Resident C was lying on her right side. Her catheter drained dark yellow urine with a large amount of sediment in the tubing. During an observation, on 6/5/24 at 10:10 a.m., the resident was lying on her right side in bed, with her covered catheter bag hanging off the bed frame and touching the floor mat along with the catheter tubing towards the door. During an observation, on 6/5/24 at 10:43 a.m., LPN 9 stopped, looked into the resident room then continued to walk to the nurse's station. During an observation, on 6/5/24 at 11:11 a.m., the resident's covered catheter bag and tubing remained laying on the fall mat on the floor towards the door. During an observation, on 6/5/24 at 11:13 a.m., CNA 10 entered the resident's room after applying a gown and gloves. During an observation, on 6/5/23…

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.