Bethel Lutheran Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Bethel Lutheran Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Nov 17, 2022

  Based on observation, review of facility policy, review of manufacturer's guidelines, review of professional reference, and staff interview, the facility failed failure to ensure sanitization of dishware (utensils, dishes, pots/pan) used to serve residents, staff, and visitors in 1 of 1 kitchen. Failure to ensure the mechanical dishwashing machine maintains the correct hot water temperature required by manufacturer's directions to destroy pathogens may result in the spread of illness and/or foodborne illness to residents, visitors, or staff During the on-site recertification survey, the team determined a potential Immediate Jeopardy (IJ) situation existed on 11/16/22 at 9:50 a.m. […]

• Actual harm, isolatedF684Apr 16, 2026

  1. Based on record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for 1 of 1 closed record (Resident #85) with an identified breast lump. Failure to ensure follow up on the identified breast abnormality prevented timely treatment interventions.Findings include: Review of the facility policy titled Bethel Lutheran Nursing & [and] Rehabilitation Center-Wound Treatment Management occurred on 04/16/26. This policy, dated February 2026, stated, Procedure . 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. […]

• Actual harm, isolatedF689Feb 7, 2024

  Based on record review, review of facility investigation, review of the facility policies, and staff interviews, the facility failed to ensure adequate supervision and assistance for 1 of 3 sampled residents (Resident #3) who required staff assistance and sit to stand mechanical lift transfers. Failure to provide adequate assistance as care planned for transfers may have resulted in Resident #3's fracture and placed all residents requiring assistance for transfers at risk for injuries. Findings include: Review of the facility policy titled Comprehensive Care Plans occurred on 02/07/24. This undated policy, stated, . It is the policy of [Facility Name] to develop and implement a comprehensive person-centered care plan for each resident, . to meet a resident's medical, nursing, and mental . […]

• No harm, potential for more than minimal, patternF550Apr 16, 2026

  Based on observation, record review, review of facility policies, and staff interviews, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's dignity for 2 of 2 sampled residents (Resident #18 and #47) and 2 supplemental residents (Resident #74 and #76) observed during meals and 1 of 1 sampled resident (Resident #56) who requested assistance in their room. Failure to treat residents with dignity and respect has the potential to affect the residents' psychosocial wellbeing and does not enhance their quality of life. Findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, occurred on 04/16/26. This policy, revised 2025, stated, . […]

• No harm, potential for more than minimal, patternF759Apr 16, 2026

  Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 3 of 6 residents (Resident #3, #12 and #77) observed during medication administration. Four medication errors occurred during staff administration of 27 medications, resulting in a 14 percent error rate. Failure to follow physician's orders and/or pharmacy recommendations may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health.Findings include:Review of the facility policy titled Crushed Medications occurred on 04/16/26. This policy, dated June 2022, stated, . […]