The Grand at Bethany Skilled Nursing and Therapy

In the surveyor’s words

From the most serious findings on record at The Grand at Bethany Skilled Nursing and Therapy, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Feb 27, 2025

  On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure staff could identify a resident's code status in an emergency. Resident #1 became unresponsive while in the whirlpool tub and CPR was initiated before the resident's code status was confirmed. The resident had a DNR in place. On [DATE] at 5:56 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On [DATE] at 6:09 p.m., the administrator and regional RN were notified of the IJ situation and provided the IJ template. On [DATE] at 5:29 p.m., the administrator was notified of an amended IJ template related to Resident #1's code status via telephone. […]

• Immediate jeopardy, isolatedF689Feb 27, 2025

  On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure a resident was supervised while in the whirlpool. Resident #1 became unresponsive while in the whirlpool tub alone and was pronounced deceased at 9:40 p.m. On [DATE] at 5:56 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On [DATE] at 6:09 p.m., the administrator and regional RN were notified of the IJ situation related to supervision in the whirlpool tub and provided the IJ template. On [DATE] at 5:29 p.m., the administrator was notified of an amended IJ template related to resident supervision while in the whirlpool via phone. […]

• Actual harm, isolatedF689Oct 9, 2024

  Based on record review, and interview, the facility failed to ensure staff followed proper transfer technique to prevent accidents for one (#2) of three sampled residents reviewed for falls. The failure resulted in a fractured femur for Resident #2. The administrator identified 106 residents resided in the facility. Findings: A Fall Program policy, revised 05/2024, read in part, develop care plan using appropriate interventions. Resident #2 had diagnoses which incldued intracerebral hemorrhage, speech deficit, and convulsions. A care plan intervention, initiated 06/25/20, documented the resident needed the assistance of two staff for transfers. A progress note, dated 09/21/24 at 6:18 p.m., documented the resident was lowered to the floor during a transfer. […]

• No harm, potential for more than minimal, patternF641Apr 24, 2025

  Based on observation, record review, and interview, the facility failed to ensure assessments were accurate for 2 (#1 and #3) of 2 sampled residents reviewed for accuracy of assessments. The DON identified 94 residents resided in the facility. Findings: 1. Resident #1's care plan, dated 02/07/25, showed they were admitted on [DATE] and discharged on [DATE] with diagnosis which included unspecified dementia, hypotension, syncope and collapse, and arteriosclerotic heart disease of native coronary artery without angina pectoris. Resident #1's admission assessment, dated 05/07/24, showed their cognition was moderately impaired for decision making with a BIMS score of 10. […]

• No harm, potential for more than minimal, patternF600Jan 13, 2025

  Based on record review and interview, the facility failed to ensure residents were [NAME] from abuse and misappropriation for two (#1 and #2) of three sampled residents reviewed for abuse. The administrator identified 109 residents resided in the facility. Findings: The facility policy titled Resident Abuse, Neglect and Misappropriation of Property, last revised 01/01/22, read in parts, The resident has the right to be free from verbal, sexual, physical and mental abuse .the facilty will not tolerate mistreatment, neglect, or abuse of residents, including sexual or .misappropriation of property. 1. Resident #1 was admitted to the facility on [DATE] with diagnoses which included cerebral infraction, DM II; hyperlipidemia, cannabis use, anxiety, quadriplegia, and retention of urine. […]