Bethany at Silver Lake

In the surveyor’s words

From the most serious findings on record at Bethany at Silver Lake, in the surveyor’s own words.

• Immediate jeopardy, patternF880May 26, 2022

  Based on observation, interview, and record review the facility failed to ensure the staff were compliant with Infection Prevention and Control Guidelines and standards of practice for four of six Units. The facility failed to ensure oversight and implementation of their Infection Prevention and Control Program during a Coronavirus Disease 2019 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) outbreak. […]

• Immediate jeopardy, isolatedF689May 26, 2022

  Based on observation, interview and record review, the facility failed to ensure hazardous chemicals were secured on three of six units including the secured Dementia Unit (South). These failures placed cognitively impaired resident's unsecured access to hazardous chemicals. The failure to safely secure hazardous chemicals caused an unsafe environment and placed residents at risk for serious injury, impairment, or death from ingestion of inappropriate substances. An Immediate Jeopardy (IJ) was called on 05/17/2022 at 4:49 PM. The IJ was removed on 05/23/2022 at 2:47 PM, after chemicals were secured and staff was educated on the dangers of unsecured chemicals. Findings included . According to the Safety Data Sheet (SDS), revised 07/22/2020, identified the Q.T. […]

• Actual harm, isolatedF600May 2, 2024

  Based on interview, and record review, the facility failed to ensure 2 of 2 sampled residents (Residents 1 and 2), who resided on a secured Special Care Unit (SCU), were free from sexual abuse. Resident 2 experienced pyshcosocial harm in the form of emotional distress, applying the reasonable person approach, when the facility failed to prevent sexual activity between two residents with cognitive deficits who were unable to consent to sexual relations. This failure placed all residents on the unit at risk of unwanted sexual contact, injury and psychological harm. […]

• Actual harm, isolatedF686Oct 31, 2023

  Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to prevent the occurrence of avoidable Pressure Ulcer/Pressure Injury (PU/PI) for 1 of 4 sampled residents (Resident 32) who was admitted without a PU/PI and had multiple co-morbidities with an increased risk for PU/PI development. Resident 32 experienced harm when they developed a Stage 3 (defined as full thickness loss of tissue) PU/PI to the resident's coccyx (tailbone region). The facility did not document refusals to reposition, or recognize the need to evaluate/modify the interventions to prevent a PU/PI when Resident 32 was non-compliant with repositioning. Thes failures placed other residents at risk for developing PU/PI's, medical complications, and unmet care needs. […]

• Actual harm, isolatedF689Apr 17, 2023

  Based on observation, interview, and record review, the facility failed to prevent a substantial injury when a resident fell from a mechanical lift device for 1 of 4 residents (Resident1) reviewed for dependent transfers. Failure to assure staff had completed competencies and return demonstration on hire, and annually, placed residents at risk of incorrect use of a mechanical lift (a transfer device machine that fully lifted and transferred the resident from surface to surface). Resident 1 experienced harm when a fall occurred while being transferred using a mechanical lift that caused a head injury that required hospital intervention and placed other residents at risk of injury. […]