Samaritan Bethany Home on Eighth

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600May 11, 2023

  Based on interview and document review the facility failed to ensure resident protection from abuse when staff restrained and forced cares that caused bruising and a skin tear for 1 of 2 residents (R1) reviewed for abuse. This resulted in an immediate jeopardy (IJ) for R1. The IJ began on 4/24/23, when nursing assistant (NA)-A caused bruising to R1's wrist when R1 was combative followed by NA-A and NA-B forcibly transferring R1 into bed, provided care against R1's wishes resulting in a skin tear, and failed to immediately implement protection measures. The acting administrator, director of nursing (DON), and assistant director of nursing (ADON), were notified of the immediate jeopardy on 5/11/23, at 2:57 p.m. […]

• Immediate jeopardy, isolatedF689Jan 27, 2022

  Based on interview and document review, the facility failed to provide necessary monitoring and supervision for 1 of 3 residents (R1) reviewed and identified at risk for elopement. R1 successfully eloped from the building, undetected, and was found by staff about three blocks away. The IJ began on 1/08/2022, at approximately 4:00 p.m. when R1 eloped and was found across the street. The administrator and director of nursing were notified of the IJ on 1/27/2022 at 3:47 p.m The immediate jeopardy was removed on 1/14/2022 when the facility implement corrected action, therefore the deficiency is being issued at past noncompliance. […]

• Actual harm, isolatedF689Mar 14, 2024

  Based on observation, interview, and document review the facility failed to follow the care plan for transfers to prevent or mitigate risk for falls and/or falls with major injury for 2 of 4 residents (R1 and R4) reviewed for falls. This resulted in actual harm for R1 who experienced a witnessed ground level fall resulting in a subdural, subarachnoid, and intraventricular hemorrhages, two left rib fractures, and a left clavicle fracture, requiring intensive care unit (ICU) hospitalization for eight days. Findings include: Subdural hemorrhage is a serious medical condition where blood collects beneath the dura mater, the outermost membrane surrounding the brain. […]

• Actual harm, isolatedF684Dec 20, 2022

  Based on interview and document review, the facility failed to follow a physician's order to report elevated blood sugars, and failed to respond to a change in condition of 1 of 3 resident's (R1) reviewed for diabetic care. This resulted in harm when R1's symptoms and significantly elevated blood sugar levels lead to re-hospitalization within five days of admission to the facility. Findings include: R1's admitting diagnosis sheet from 12/13/22 indicated diagnoses that included type 2 diabetes mellitus with hyperglycemia (late on-set diabetes with an associated issue of high blood sugars), a recent case of COVID-19, weakness, a fall and subsequent fractures of pubic bone and left hip socket. […]

• No harm, potential for more than minimal, patternF552Mar 26, 2026

  Based on interview and document review, the facility failed to obtain and document an informed consent, including with explanation of risk and benefits and alternatives for psychotropic medications for 3 of 5 residents (R10, R22) reviewed for unnecessary medications.Findings include:R22R22's admission Minimum Data Set (MDS) assessment, dated 3/10/26, indicated R22 had intact cognition with no hallucinations, delusion, or rejection of care. MDS indicated R22 was on an antidepressant (psychotropic medication).R22's medical diagnosis report, dated 3/24/26, included the following relevant diagnoses: major depressive disorder, acute respiratory failure with hypoxia (a critical condition where the lungs are unable to adequately oxygenate the blood), acute on chronic congestive heart failure (a… […]