Betania Care Home LLC

Based on documentation review and interview, when a resident had an accident resulting in the resident needing medical services, the manager failed to ensure a caregiver immediately notified the resident's primary care provider. Findings include: 1. A documentation review of facility incident reports revealed an incident report dated May 22, 2025. The incident report stated, "Resident was in the restroom, hear a big noise and found [R3] on the floor lying on [R3's] right side, [R3] stated [R3] did not hit [R3's] head, but had pain in [R3's] tailbone... put pillow on [R3's] head and called 911 to come to check [R3] and helped me to get [R3] up." The incident report documented the resident's representative was notified immediately, however, the incident report did not document notification of [R3]'s primary care provider. 2. In an interview, E1 acknowledged the incident report provided for review did not include documentation of the immediate notification of R3's primary care provider when R3 had an accident and required medical services.

Based on observation and interview, the manager failed to ensure an accurate list of resident rights was conspicuously posted. R9-10-810(B)(2)(i) states: "A manager shall ensure that: A resident is not subjected to: Restraint;" Findings include: 1. During an environmental tour, the Compliance Officer observed a posted list of resident's rights by the front door. However, the posting stated, "B) A manager shall ensure that:...2) A resident is not subjected to:...i. Restraint, if not necessary to prevent imminent harm to self or others; 2. In an interview, E1 acknowledged the posted list of resident rights did not include the current rights required per R9-10-810.B. Technical assistance for this rule was provided during the on-site compliance inspection conducted on July 7, 2022.

Based on record review and interview, the manager failed to ensure a resident had a written service plan, when updated, was signed and dated by the manager, for one of three residents sampled. Findings include: 1. A review of R3's medical record revealed a written service plan dated March 27, 2023, for directed care services. However, the service plan was not signed and dated by the manager. 2. In an interview, E1 acknowledged R3's written service plan was not signed and dated by the manager.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for one of three residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated May 4, 2023, for personal care services. The service plan included provision of the following services: - "Identified Problem, Incontinence Bladder Bowel. F/C in place - Nurse to provide f/c management." 2. A review of R1's medical record revealed a document titled, "Activities of Daily Living," (ADL) dated June 2023. The ADL documented services provided to R1 during the month of June 2023. However, the ADL did not document foley catheter care provided to R1 during the month of June 2023. 3. In an interview, E1 reported R1 required assistance with R1's foley catheter on a daily basis, including changing from the bed bag to the leg bag, emptying the catheter bag, and sanitizing the bags daily. E1 acknowledged documentation of the catheter care services provided to R1 had not been documented in R1's medical record.

Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a cabinet above the kitchen sink had magnetic locks, however, the locks had been manually disengaged and the cabinet was accessible to residents. Inside the cabinet, the Compliance Officer observed food items including mandarins and potato chips. Also inside the cabinet, the Compliance Officer observed a prescription bottle of, "Acetaminophen 500 MG tablets." 2. In an interview, E1 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.