Bethany on 42ND

In the surveyor’s words

From the most serious findings on record at Bethany on 42ND, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF641Mar 14, 2024

  42397 Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 25 sampled residents (Resident #6, #9 and #51) and two supplemental residents (Resident #44 and #85). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION A: IDENTIFICATION INFORMATION The Long-Term Care Facility RAI Manual, revised October 2023, pages A-30 thru A-32, . A1500: Preadmission Screening and Resident Review (PASRR) . […]

• No harm, potential for more than minimal, patternF550Mar 30, 2023

  Based on resident and family interviews and facility policy, the facility failed to provide care in a manner that maintains or enhances resident dignity for 7 of 7 (Resident A, B, C, D, E, F, and G) confidential sampled resident interviews and 3 confidential family interviews. Failure to answer call lights promptly, provide care in a dignified manner, and treat residents respectfully does not enhance the resident's quality of life and may result in decreased self-esteem, incontinence, and skin breakdown. Findings include: Review of the facility policy titled Dignity occurred on 03/30/23. […]

• No harm, potential for more than minimal, patternF641Mar 30, 2023

  Based on record review and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), the facility failed to complete a Minimum Data Set (MDS) that accurately reflected the residents' status for 4 of 4 sampled residents (Resident #18, #38, #63, and #64) and 1 supplemental resident (Resident #55) reviewed for Preadmission Screening and Resident Review (PASRR). Failure to accurately code the MDS may negatively affect the development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI Manual, revised October 2019, page A22-A23, stated, . A1500: Preadmission Screening and Resident Review (PASRR) . […]

• No harm, potential for more than minimal, patternF760Mar 30, 2023

  Based on record review, review of a professional reference, and staff interview, the facility failed to ensure a resident remained free from significant medication errors for 1 supplemental resident (Resident #95) reviewed for dialysis. Failure to administer medications according to the practitioner's order and report frequently missed doses to the practitioner, may inhibit the effectiveness of the medications and cause subtherapeutic levels. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 816, stated, Because the purpose of most drug therapy is to maintain a constant drug level in the body, repeated doses are required to maintain that level. […]

• No harm, potential for more than minimal, patternF804Mar 30, 2023

  Based on observation, review of facility policy, and resident interviews, the facility failed to serve foods at palatable temperatures for 2 of 8 units (Meadowlark Lane and Crestwood). Failure to serve foods at a temperature acceptable to residents may result in decreased intake, weight loss, and inadequate nutrition. Findings include: Review of the facility policy titled Service of Food occurred on 03/30/23. This policy, revised December 2021, stated, 1. Hot foods will be held until service at 135 degrees F. [Fahrenheit] or above. 2. Hot foods should be at least 120-130 degrees F. when presented to the residents. […]