Bethany Lutheran Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Oct 2, 2025

  Based on observation, clinical record review, staff interviews, and policy review the facility failed to protect a resident from possible accidents and injuries for 1of 2 residents (Resident #38). The facility failed to provide adequate supervision to prevent elopement. On 7/20/25 between 4:30-4:40 PM the staff last saw Resident #38 standing by the front door where visitors were exiting. The door alarm sounded with Staff A responding to the alarm but he failed to locate Resident #38 and went back to his previous duties being unaware Resident #38 was outside. […]

• Immediate jeopardy, isolatedF684Nov 2, 2023

  Based on clinical record review, staff interviews, transportation driver interview, clinic staff interview, family interviews, facility document review and facility policy the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice. A nurse failed to complete an assessment and intervene with a significant change. The resident was unresponsive prior to leaving for an appointment, after Oxycodone a schedule 2 opiate (narcotic) was given. At the clinic appointment the resident was found to be unresponsive with a blood pressure of 62/38 and a faint pulse. Narcan, an opiate antagonist was given. Primary diagnosis at appointment was unresponsiveness. Resident #1 was transferred to the emergency room from the clinic via ambulance. […]

• Immediate jeopardy, isolatedF760Dec 8, 2022

  Based on observation, record review, and staff interviews, the facility failed to ensure residents did not experience significant medication errors for 1 of 4 residents reviewed (Resident #2). On 11/1/22, a recently admitted (10/24/22) Resident #2 went to a doctor's appointment at a clinic where labs were drawn. The physician identified the facility failed to administer the resident's insulin and 2 oral diabetic medications (meds) that the physician written upon the resident's admission to the facility. The physician notified the facility of their oversight, and they gave Resident #2 one of the ordered medications from the Emergency Box. But, they ultimately did not administer all 3 of Resident #2's omitted meds until 11/3/22. […]

• Immediate jeopardy, isolatedF689Dec 1, 2021

  Based on observations, clinical record review, family and staff interviews, facility investigative file review, and facility policy review, the facility failed to provide adequate nursing supervision and assistance devices to prevent hazards for 2 of 9 residents reviewed. (Resident #2 and #25). On 5/24/21 Resident #2 admitted to the facility from an Assisted Living because she had eloped (when a resident leaves the facility without staff knowledge or permission) twice and the facility was unable to keep her safe. In addition, the family reported the resident had eloped from their home prior to her stay at the Assisted Living Facility and indicated they informed the nursing facility of her past history of eloping from their home and from Assisted Living. […]

• Actual harm, isolatedF658May 30, 2025

  Based on clinical record review, facility policy review, staff interviews, and the provider interview, the facility failed to ensure the orders of 1 of 3 residents (Resident #2) were implemented after a 30-day review was completed by the ordering Nurse Practitioner. Resident #2 was ordered morphine sulfate (opioid used to treat severe pain) 15 milligrams (mg) twice a day (BID) for pain. The order was a durational order to be reviewed every 30 days by the Nurse Practitioner for continued use. During the Nurse Practitioner's visit with the resident on 3/20/2025 she noted to continue with the scheduled and as needed (PRN) orders for morphine. […]