Bethany Home - Brandon

In the surveyor’s words

From the most serious findings on record at Bethany Home - Brandon, in the surveyor’s own words.

• Immediate jeopardy, patternF812Nov 8, 2024

  Based on observation, interview, record review, and policy review, the provider failed to: *Ensure that staff were able to verify the chemical sanitation level required to clean the main kitchen surfaces used for the preparation of residents' food. Failure to ensure that increased the potential risk of foodborne illnesses for the entire resident population who received meals prepared in the main kitchen. *Maintain the dishwasher sanitation rinse cycle temperature at a minimum of 180 degrees Fahrenheit per the manufacturer's manual for two of four kitchenette dishwashers. […]

• Actual harm, isolatedF760May 28, 2026

  Based on a South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to ensure residents were free of significant medication errors for one of one sampled resident (3) who received 2.5 milliliters (mL) of Morphine Sulfate (narcotic) by mouth instead of the ordered dose of 0.25 mL from a certified nursing assistant (CNA)/medication aide (MA) E and experienced decreased oxygen levels, lethargy (abnormal drowsiness or sluggishness that involves low energy, decreased alertness, reduced mental and physical activity), respiratory distress (trouble breathing), and required the use of Narcan (a medication that reverses the effects of opioids).Findings include:1. […]

• Actual harm, isolatedF689Oct 21, 2025

  Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, interview, observation, record review, and policy review, the provider failed to ensure certified nursing assistant (CNA) L had used the whirlpool bath chair safety belt according to the provider's policy during resident 6's bath, CNA K had used the whirlpool bath chair safety belt according to the provider's policy during resident 7's bath, and CNA M had followed resident 4's care plan regarding safe transfers with the mechanical lift equipment. Resident 6 fell out of the bath chair and sustained a pelvic fracture. Resident 7 fell out of the bath chair and sustained multiple fractures to her lower spine, pelvis, and tibia. […]

• Actual harm, isolatedF689May 29, 2025

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure the safety of one of one sampled resident (3) who fell out of her wheelchair and received a laceration to the left side of her forehead that required sutures. The fall was related to assistive devices (wheelchair pedals) not being in place to prevent an accident. Findings include: 1. Review of the provider's 3/15/25 SD DOH FRI regarding resident 3 revealed: *On 3/15/25 at 8:30 a.m. certified nursing assistant (CNA) Q yelled out while in resident 3's room. *CNA D responded and went to assist resident 3 in her room and alerted licensed practical nurse (LPN) R that resident 3 was on the floor. […]

• No harm, potential for more than minimal, widespreadF801Nov 8, 2024

  Based on observation, interview, record review, and job description review the provider failed to ensure the dietitian and dietary director carried out the functions of the food and nutrition services department to ensure the development and implementation of policies and procedures regarding appropriate cleaning, sanitization, and record-keeping were completed in the food and nutrition departments that included the main kitchen and four kitchenettes. Failure to ensure this oversight of the food and nutrition services department increased the potential risk of foodborne illnesses for the entire resident population who received meals that were prepared in the main kitchen and served from the kitchenettes. Findings Include: 1. Refer to F812 2. Interview on 11/08/24 at 12:36 p.m. […]