Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethel Lutheran Home during CMS and state inspections, most recent first.
An LVN entered a resident’s room without gown and gloves while the resident was on contact precautions for MRSA and provided care after touching the resident, bed, and pillows. In the kitchen, a dietary cook prepared food with his side beard exposed and not fully covered by a hair restraint. The DON, IP, and Dietary Supervisor stated PPE and full hair coverage were required, and the facility policy and FDA Food Code were not followed.
Incomplete Controlled Substance Destruction Records: The DON and Consultant Pharmacist destroyed 37 controlled substance medications for 23 residents, but the controlled drug disposition log did not include the DON’s RN witness signature for the destruction entries. Interviews confirmed both signatures were required to verify the medication and quantity destroyed, and the facility policy required a witness signature on the medication disposition record.
Incomplete medication labeling and expired medication were found in medication storage areas. An LPN observed a resident’s morphine sulfate with no expiration or use-by date on the pharmacy label, and another resident’s discontinued triamcinolone acetonide injection kit was still in the medication refrigerator after expiration. The DON and CP stated pharmacy labels were required to include expiration dates and that expired or discontinued medications should not remain in carts or medication rooms.
A dietary cook and another dietary staff member served sea greens to residents on regular texture, regular portion diets using a #10 scoop instead of the #8 scoop listed in the recipe. The DS, RD, and DON stated the recipe and diet orders were expected to be followed, and the DON confirmed the facility policy was not followed when the incorrect portion size was served.
Expired and improperly labeled food items were found in the dry good pantry and kitchen prep area, including expired bread, an expired seasoning bottle, and two opened cereal containers without clear received, opened, or expiration dates. In the serving prep fridge, a bottle of lemon juice was stored beneath meat and had a sticky yellow residue on it, and staff stated it should have been clean and protected from cross contamination. The DS, RD, and DON all stated food items were required to be dated, removed when expired, and stored in a sanitary manner.
Failure to Implement Resident’s Care Plan Interventions: A resident with Alzheimer’s disease, dementia, muscle weakness, difficulty walking, and severe cognitive impairment had a care plan listing 1:1 supervision while awake and a bolster mattress for fall risk, but observations showed she was sitting by her bed without staff present and her bed lacked bolsters. CNAs, an LVN, the IP, and the DON all stated the care plan was not accurate, not person centered, and not being followed as written.
A resident with diverticulitis, osteoarthritis, and osteoporosis received Tylenol for mild pain without a prior pain assessment. An LVN administered the medication even though the order lacked an indication for use and an associated pain scale. The CP and DON stated medication orders required an indication and that nursing staff were expected to assess pain before giving pain medication.
Incomplete Inventory of Personal Effects Form: A resident’s admission inventory form was left incomplete, with missing resident/RP signature, witness information, physician name, MR number, and room/bed details. CNA, LVN, MR, and DON all confirmed the form was not fully completed, and staff noted the resident had confusion and could not sign, so the RP should have signed the document. The facility’s documentation policy required records to be complete and accurate.
Missing CNA Abuse In-Service Documentation: The facility failed to document required 2025 abuse in-service training for one CNA, who was a full-time employee. The DSD/IP and DON confirmed the CNA was not accounted for on the abuse training sign-in sheet, and the facility's P&P required all nurse aide personnel to participate in regular in-service education, including annual training on resident abuse prevention and abuse, neglect, and exploitation.
A facility failed to ensure 22 shared resident rooms provided at least 80 sq ft per resident. Surveyors observed two residents in each room, and the ADM confirmed the rooms measured 154 sq ft total, or 77 sq ft per resident. The report noted the rooms still met resident needs, with reasonable privacy, adequate storage, bedside stands, and sufficient space for care and mobility.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not provide further details about the specific actions or events involved.
A nurse attempted to obtain a urine specimen from a resident by straight catheterization without a physician's order, making two unsuccessful attempts before collecting the specimen via bedpan. The resident, who was cognitively intact and had significant medical conditions, was confused and nervous during the procedure. The nurse did not notify the physician or responsible party and was unaware that a physician's order was required, contrary to facility policy and expectations.
A male CNA violated the privacy and dignity of two residents by laying in bed with one resident, which was observed by her roommate. The incident was confirmed through interviews and video footage, revealing the CNA's inappropriate behavior. Both residents were cognitively intact and expressed discomfort, highlighting a breach of their rights to dignity and freedom from abuse.
The facility failed to ensure thorough and complete orientation and education documentation for two CNAs, as verified by the DSD. Records for both CNAs were missing signatures, dates, and other necessary information to confirm completion of required training. The Administrator confirmed these deficiencies, highlighting a lack of supervision and verification in the training process.
A facility failed to ensure a CNA received thorough education on Resident Rights, as required by its policies. The DSD did not complete or verify the necessary training, leaving the Employee Orientation document unsigned. This led to CNA 1 working without proper instruction on Resident Rights, resulting in their termination for violating these rights.
The facility failed to maintain food safety standards, with issues including freezer-burned meat, unlabeled staff food, and improperly dated yogurt in storage areas. Additionally, food items brought by family members for two residents were not labeled with dates, risking the consumption of expired food. These deficiencies were acknowledged by the Dietary Service Supervisor and Registered Dietitian, highlighting the potential for foodborne illnesses.
A facility failed to ensure privacy for two residents during medical treatments. An LVN did not pull curtains or close the door while performing a blood glucose test and administering insulin to a cognitively intact resident, exposing him to view. In another instance, the same LVN administered eye drops to a resident with severe cognitive impairment without drawing the curtains, allowing the roommate to observe. Staff interviews and facility policies confirmed the importance of maintaining privacy, which was not upheld in these cases.
A resident experienced pain and discomfort during a transfer from a wheelchair to a bed due to the improper use of a Hoyer lift sling by CNAs. The resident, with a history of muscle contracture and back surgery, was lifted in a sitting position instead of a reclined position, contrary to the manufacturer's guidelines. Staff interviews revealed a lack of awareness of the correct procedure, and the Director of Nursing confirmed the guidelines were not followed.
The facility failed to ensure proper labeling and storage of medications, with issues including missing expiration dates on pill packets, unlabeled medication containers inside boxes, and a medication refrigerator below the required temperature range. Staff acknowledged these deficiencies, and the DON emphasized the importance of correct labeling and storage to prevent harm and maintain medication potency.
The facility failed to ensure that residents received food at a safe and appetizing temperature. The Dietary Cook did not check the temperature of food on the steam table before serving, which is crucial for food safety and palatability. The absence of temperature checks was confirmed by the Dietary Services Supervisor and the Registered Dietitian, highlighting a breach in the facility's policy requiring food to be held at a minimum of 140 degrees Fahrenheit.
The facility failed to maintain the B-wing medication refrigerator at a safe temperature, risking medication safety. The refrigerator was observed at 32°F, below the acceptable range, potentially damaging medications. Staff acknowledged the issue, and the Maintenance Director noted a lack of regular checks and maintenance logs for the refrigerator.
A resident with chronic pain conditions did not receive prescribed analgesics before physical therapy sessions, as outlined in their care plan. Despite frequent complaints of pain, staff failed to administer pain medication, resulting in unmanaged pain during therapy. Interviews with staff, including an LVN and the MDS Nurse Coordinator, confirmed the oversight, highlighting a lack of adherence to the care plan.
A resident with chronic pain conditions was not given prescribed analgesia before physical therapy, leading to significant discomfort during transfers and therapy sessions. Despite a care plan specifying the need for pain management, staff failed to administer the medication, resulting in the resident experiencing unnecessary pain. The oversight was acknowledged by multiple staff members, including the DON, who confirmed the care plan was not followed.
A resident with multiple medical conditions, including diabetes and hypertension, was served an incorrect portion size due to the dietary staff using a larger scoop than prescribed. This failure to follow the physician's order for a small portion diet was observed during a tray line in the kitchen, and confirmed by both the Dietary Services Supervisor and the Registered Dietitian.
A resident with diverticulitis and malnutrition was served meals not aligned with her preferences, including chicken with skin and beets, despite her dietary restrictions. Staff interviews revealed a lack of proper checks and communication regarding meal preferences, with responsibilities shared between nurses and CNAs. The facility's policy emphasized the importance of aligning meals with residents' informed choices and treatment goals.
A resident with severe cognitive impairment was at risk due to incomplete antipsychotic consent forms, as the physician's signatures were not dated. The DON and LVN acknowledged the oversight, emphasizing the importance of dated signatures to verify informed consent before medication administration. The facility's policies and job descriptions underscored the need for accurate and complete medical records.
A contractor technician failed to wash his hands upon entering the kitchen and scooped ice from the ice machine, potentially causing cross-contamination and foodborne illnesses for 56 residents, staff, and visitors. Interviews with the DSS and RD confirmed the importance of handwashing to prevent the spread of germs, as outlined in the facility's infection control policy.
The facility failed to meet the minimum space requirement of 80 square feet per resident in multiple rooms, with 22 rooms measuring only 154 square feet for two residents each. Despite this, staff and residents reported no issues with room size, privacy, or care space. Observations confirmed adequate privacy and space for care, and a waiver continuation was recommended.
Failure to Use PPE for Contact Precautions and to Fully Cover Facial Hair in Kitchen
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when an LVN entered Resident 1’s room without wearing PPE while the resident was on contact precautions for an MRSA wound. Resident 1’s record showed diagnoses including hemiplegia, hemiparesis following cerebral infarction affecting the right dominant side, and MRSA infection. The resident’s MDS assessment showed a BIMS score of 7, indicating severe cognitive impairment. A contact precautions sign was posted on the door, and gown and gloves were available outside the room, but the LVN entered without PPE and turned the resident’s body while adjusting pillows under the resident’s right side, making contact with the resident, bed, and pillows. During interview, the LVN stated the resident was on contact precautions for MRSA and that the expectation was to wear a gown and gloves before interacting with the resident. The LVN acknowledged she did not put on PPE before providing care and stated she should have done so. The Charge LVN, Infection Preventionist, and DON all stated PPE was required before entering the room and that the facility’s isolation policy was not followed. The Infection Preventionist stated the resident had a highly contagious MRSA diagnosis and that staff should gown and glove before entering and remove PPE before leaving the room. The facility also failed to maintain infection control in the kitchen when a dietary cook was observed preparing food with his side beard exposed and not fully covered by a hair restraint. The Dietary Supervisor observed the cook and stated all hair, including facial hair, must be covered at all times. The cook adjusted his hair restraint and washed his hands after the issue was identified. The DSD/Infection Preventionist and DON stated the expectation was that all hair be covered in the kitchen to prevent hair from falling into food and contaminating it. The facility’s diet type report showed that all 49 residents received food from the kitchen, and the facility policy and FDA Food Code required hair restraints, including beard restraints, to keep hair from contacting food and related items.
Incomplete Controlled Substance Destruction Records
Penalty
Summary
Pharmaceutical services failed to keep accurate controlled substance records for 23 residents when 37 controlled substance medication entries from 6/26/25 through 11/18/25 did not have a RN witness signature for destruction in the controlled drug disposition log on 11/20/25. During interview and record review, the DON stated the controlled drug disposition log required all entries to be completed and accurate, and that she and the Consultant Pharmacist destroyed controlled medications together and both signed the log to verify the medications were accounted for and disposed of correctly. The DON stated she destroyed 37 controlled substance medications for 23 residents with the Consultant Pharmacist but did not sign the entries as the witnessing RN. The DON stated her signature was required to verify the correct medication and quantity were destroyed and that the log needed to be completed accurately to prevent drug diversion and ensure all controlled substances were accounted for. The Consultant Pharmacist stated he destroyed controlled substances with the DON, verified the medication and quantity before destruction, and required both signatures on the log to ensure accurate tracking and destruction. The facility policy titled, Discarding and Destroying Medications, stated the medication disposition record must include a witness signature.
Incomplete Medication Labeling and Expired Medication Stored
Penalty
Summary
Drugs and biologicals were not accurately labeled and stored in one medication cart and one medication room. In medication cart B behind nursing station B, Resident 30’s morphine sulfate 15 mg prescription medication was observed with no use-by or expiration date on the pharmacy label. LVN 3 stated the medication had not been administered since it was ordered and could not locate an expiration or use-by date on the label. LVN 3 also stated all prescription medications from the pharmacy should be delivered with an expiration or use-by date, and that the receiving nurse should have identified the missing date and reported it to the pharmacy. In medication room C behind nursing station C, Resident 6’s triamcinolone acetonide injection kit 40 mg/ml was observed with an expiration date of 11/29/25. LVN 4 stated the medication was expired and should not have been in the medication refrigerator. The OSR showed Resident 6 no longer had an active order for the medication and that it had been discontinued on 6/4/25. LVN 4 stated night shift nurses perform medication room audits and remove discontinued and expired medications nightly, but this medication remained in the refrigerator after discontinuation and after expiration. The consultant pharmacist stated monthly medication cart and medication room audits were performed to assess and remove expired and discontinued medications and ensure medications were labeled accurately. The DON stated the pharmacy label on Resident 30’s morphine sulfate did not have an expiration date and that the medication should have been checked when received. The DON also stated Resident 6’s discontinued triamcinolone acetonide injection kit should have been removed from the medication refrigerator when it was discontinued, before it expired. The facility policy required medication labels to include an expiration date and directed staff to contact the dispensing pharmacy if labels were missing, incomplete, improper, or incorrect.
Incorrect Portion Size Served During Lunch Tray Line
Penalty
Summary
The facility failed to ensure that 19 of 49 residents receiving meals from the kitchen were served the correct portion of sea greens for lunch. On 12/3/25, residents on regular texture and regular portion diets were served sea greens using a #10 scoop, which equals 3/8 cup, instead of the #8 scoop, which equals 1/2 cup, as listed in the recipe for Sea Greens #2. The report states that 19 residents received the wrong caloric intake as a result of the incorrect serving size. During a concurrent observation and interview in the kitchen during lunch tray line, Dietary staff were observed serving lunch items including meat and beans, potatoes, spinach/sea greens, and cornbread. DC 1 was observed placing a #10 scoop in the sea greens container and using that scoop to serve residents with regular diet textures and portions. DC 1 stated he used the Sea Greens #2 recipe and that serving scoop sizes were expected to be followed. DC 2 was also observed using a #10 scoop to serve sea greens to residents on regular diets and stated he was using that scoop size for those trays. The Dietary Supervisor stated the Sea Greens #2 recipe called for a #8 scoop and that DC 1 and DC 2 used the incorrect #10 scoop. The DS stated dietary cooks were responsible for preparing, making, and serving scheduled menu items per recipe and that following recipe guidelines was important to ensure residents received the correct nutrition ordered for their diet. The RD and DON both stated recipes and diet orders were expected to be followed, and the DON stated the facility policy was not followed when residents on regular texture diets with regular portions were served sea greens with a #10 scoop.
Expired and Improperly Stored Food Items
Penalty
Summary
Food and beverage storage and handling were not maintained in accordance with professional standards in the facility’s dry good pantry, kitchen preparation area, and serving preparation refrigerator. During observation with the Dietary Supervisor, three packages of bread were found expired with an expiration date of 11/30/25 and were still stored in the dry good pantry. The Dietary Supervisor stated the bread should have been removed on its expiration date. Two opened cereal containers in the dry good pantry were labeled only with initials and a date, but the labels did not identify whether the date represented received, opened, or expiration information. The Dietary Supervisor stated opened cereal transferred into containers was required to be labeled with received, opened, and expiration dates, and could not state what the dates on the two containers represented. In the kitchen preparation area, one opened bottle of crushed rosemary seasoning was found expired with an expiration date of 8/15/24. The Dietary Supervisor stated the seasoning was expired and should not have been in the kitchen for use. In the serving preparation refrigerator, a bottle of lemon juice was stored on a lower shelf beneath turkey lunch meat and hot dogs and had a wet, yellow spotted sticky substance on the top and sides of the bottle. Staff stated the bottle should have been clean and free from debris and should not have been stored under meat because of possible cross contamination. The RD and DON both stated expired items were to be removed, food items were to be properly labeled with received, opened, and expiration dates, and food was expected to be stored clean and free from cross contamination. Facility policies and an in-service on labeling and dating also stated food items were to be labeled, dated, and discarded if missing a label.
Failure to Implement Resident’s Care Plan Interventions
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 9. Resident 9 was admitted with unspecified Alzheimer’s disease, unspecified dementia, muscle weakness, and difficulty walking. Her MDS assessment showed a BIMS score of 00 out of 15, indicating severe cognitive impairment. The care plan report identified her as at risk for falls and repeated falls related to Alzheimer’s disease, anxiety, dementia, difficulty walking, generalized muscle weakness, and a history of falling, with interventions listed as 1:1 supervision while awake and a bolster mattress. During observation, Resident 9 was seen sitting in a wheelchair next to her bed without staff present, and her hospital bed did not have bolsters or any other additions. In a later observation, she was again sitting next to her bed in a wheelchair without 1:1 supervision and without a bolster mattress on the bed. CNA 2 stated Resident 9 was not to be supervised with 1:1 care and said that if the care plan was not correct, staff could give the wrong care. CNA 4 stated care plans should be known by all staff and guide daily care. LVN 1 stated Resident 9 did not have 1:1 supervision or a bolster mattress and said the care plan was not individualized, comprehensive, or person centered because the listed interventions were not being provided. The LVN stated the care plan was wrong and the care being provided was not accurate. The IP stated the care plan was not person centered or comprehensive and needed to be updated to the resident’s individual needs. The DON stated Resident 9 had needed 1:1 staff support and bolsters at one point, but that was not the level of care she needed now, and acknowledged the care plan was not up to date, person centered, or comprehensive.
Pain Medication Given Without Assessment or Complete Order Instructions
Penalty
Summary
The facility failed to meet professional standards of practice for one of thirteen sampled residents during medication administration. Resident 6 was admitted with diagnoses of diverticulitis, osteoarthritis, and age-related osteoporosis. The resident had an order for Tylenol 325 mg, 2 tablets by mouth every 6 hours for mild pain, with a start date of 6/8/25. During a medication pass observation, an LVN administered 2 tablets of Tylenol 325 mg to Resident 6 without performing a pain assessment first. The resident was observed taking the medication, and the LVN did not assess whether the resident had pain before giving the dose. During interview, the LVN stated the order did not include an indication for use or an associated pain scale to guide administration and stated she did not complete a pain assessment prior to administration to confirm mild pain. The CP stated medication administration instructions required an indication for use and that licensed nursing staff were expected to complete pain assessments before administering pain medication. The DON stated the Tylenol order did not have an indication for use or an associated pain scale and that licensed nursing staff were expected to perform pain assessments prior to all scheduled, routine, and as-needed pain medication. The DON also stated facility policy was not followed when Resident 6 did not receive a pain assessment and when the Tylenol order lacked an appropriate indication and pain rating scale.
Incomplete Inventory of Personal Effects Form
Penalty
Summary
The facility failed to ensure that Resident 64’s medical record was complete when the Inventory of Personal Effects form was left incomplete on admission. The form, dated 11/19/25, did not include documentation of the resident or resident representative signature and date, witness signature, title of witness and date, attending physician name, record number, or room/bed information. During interview, CNA 1 stated the Inventory of Personal Effects form is completed on admission by the CNA, signed by the CNA, and then given to the nurse, and that it should be filled out accurately and completely so staff know what belongings were brought into the facility and can track resident items. LVN 2 reviewed the form and stated it was missing several items of information, including the attending physician name, room number, witness signature, and RP signature. LVN 2 also stated Resident 64 had episodes of confusion and could not sign the form, so the RP should have signed it. Medical Records staff stated she was responsible for auditing resident records after admission and remembered giving the form to the CNA with only the resident’s name written on it. She stated the form was not complete and was missing the physician name, medical record number, and RP signature. The DON also reviewed the form and stated it was not complete because there was no RP or resident signature, no physician name, no medical record number, and no room number. The DON stated the facility’s policy required medical records to be complete and accurate, and the policy titled Charting and Documentation stated documentation in the medical record must be objective, complete, and accurate.
Missing CNA Abuse In-Service Documentation
Penalty
Summary
The facility failed to have documentation of abuse in-service training for 2025 for one of three certified nursing assistants reviewed, identified as CNA 4. During a concurrent interview and record review with the DSD/IP and DON, the abuse in-service training sign-in sheet for employed CNAs was reviewed and showed CNA 4 was not accounted for as having completed the required abuse in-service for 2025. The DON stated CNA 4 was a full-time employee. During interviews, the DSD/IP stated she was responsible for the abuse trainings but was not the DSD at the time the trainings were conducted, and that the expectation was all CNAs received the required training, but CNA 4 was missing. The DSD/IP stated abuse training was important to educate staff on how to recognize and report abuse with residents. The DON stated CNAs need to attend all required trainings and be proficient with the information learned, and that CNA 4 not receiving the required abuse training was a safety concern. Review of the facility's P&P In-Service Training, All Staff showed all nurse aide personnel participate in regular in-service education, including annual training in resident abuse prevention and abuse, neglect, and exploitation of residents, with participation documented by the staff development coordinator.
Insufficient Bedroom Space per Resident
Penalty
Summary
The facility failed to ensure that each bedroom had at least 80 square feet of usable living space per resident in 22 of 29 rooms, including Rooms 27, 28, 29, 31, 32, 33, 34, 35, 36, 47, 48, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, and 60. During the survey period, observation and staff interview showed that these rooms each had two residents and measured 154 square feet total, which equaled 77 square feet per resident. The Administrator stated awareness that these rooms did not meet the minimum space requirement for two residents and provided the room measurements. Surveyors observed throughout the survey period that the 22 resident bedrooms had two residents per room and less than 80 square feet of space for each resident. The report states that although the bedrooms accommodated less than 80 square feet per resident, each room met the required needs of the residents. The residents had a reasonable amount of privacy, closet and storage space was adequate, bedside stands were available, and there was sufficient room for nursing care and resident mobility. Wheelchairs, devices, and toilet facilities were accessible.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved. No further information about the circumstances, individuals affected, or specific observations is included in the report.
Urine Catheterization Performed Without Physician Order
Penalty
Summary
A Licensed Vocational Nurse (LVN) attempted to obtain a urine specimen from a resident by performing a straight catheterization without a physician's order. The resident, who was cognitively intact and had a history of hemiplegia, metabolic encephalopathy, and malignant neoplasm of the brain, recalled being confused and nervous during the procedure, as she had previously been able to provide urine specimens using a hat. The LVN made two unsuccessful attempts to insert the catheter before ultimately collecting the specimen via bedpan, without notifying the physician or the resident's responsible party. The LVN stated she was unaware that a physician's order was required for this procedure, as it had been standard practice at her previous place of employment for incontinent residents. Facility policy and procedure documents reviewed indicated that a physician's order is required for invasive procedures such as straight catheterization and for obtaining urine specimens. The Director of Nursing confirmed that the LVN had attempted the procedure without an order and acknowledged that straight catheterization is considered invasive. The facility's administrator also acknowledged that the LVN's actions were not in line with facility expectations, which require staff to follow physician orders, adhere to policy, and document all interactions and communications.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to respect the rights of two residents to a dignified private and personal space when a male CNA laid down on the bed with one of the residents, Resident 1, and took a nap. This incident was observed by Resident 1's roommate, Resident 2, leading to potential psychosocial harm such as emotional distress for both residents. The incident was confirmed through interviews and video footage review, which showed the CNA entering and remaining in the room for approximately 16 non-consecutive minutes. Resident 2, who is cognitively intact, reported the incident to the Administrator, stating that she saw the CNA in Resident 1's bed under the blankets. Resident 1, also cognitively intact, confirmed the CNA's presence in her bed and expressed discomfort about the situation. The facility's documentation and interviews with other CNAs corroborated the incident, with one CNA expressing regret for not reporting the behavior sooner. The facility's Resident Rights document emphasizes the right to dignity and freedom from abuse and neglect, which were violated in this incident. The CNA's actions were not aligned with these rights, as they compromised the residents' dignity and personal space. The facility's response included an investigation and interviews with involved staff and residents, confirming the inappropriate behavior of the CNA.
Incomplete Staff Training Documentation
Penalty
Summary
The facility failed to ensure that the orientation and education documentation for two Certified Nursing Assistants (CNAs) was thorough and completed by the Director of Staff Development (DSD). During a review of CNA 1's education records, it was found that several documents, including a training record and an employee orientation checklist, were incomplete. These documents lacked signatures, dates, and other necessary information to verify that the required training and orientation had been completed. The DSD admitted to not signing the training record, and the employee orientation checklist was entirely blank. Similarly, CNA 3's education records were reviewed and found to be incomplete. A training record was missing the name of the instructor, and the employee orientation checklist was unsigned and undated. The Administrator confirmed these findings and stated that it was expected for new hire education to be supervised and verified by the DSD. This lack of documentation and verification could potentially lead to inadequately trained staff working with residents.
Failure to Educate CNA on Resident Rights
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA 1) received thorough education on Resident Rights, as required by the facility's policies and procedures. The Director of Staff Development (DSD) did not complete or verify the necessary training for CNA 1, which was evident from the incomplete Employee Orientation document. This document, which should have been signed by CNA 1 and a licensed nurse, was left blank, indicating that CNA 1 had not been properly instructed in Resident Rights before assuming direct-care responsibilities. The deficiency was further highlighted by a letter from the facility, dated November 14, 2024, which terminated CNA 1's employment due to a violation of resident rights. The Administrator confirmed that it was expected for new hires to have their in-service education supervised and precepted by the DSD. The facility's policy clearly stated that staff must receive appropriate in-service training on resident rights prior to providing direct care, which was not adhered to in this case.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as evidenced by several observations in the kitchen and resident rooms. In the walk-in freezer, a bag of beef stew meat was found with ice crystals, indicating freezer burn, which the Dietary Service Supervisor (DSS) acknowledged should have been discarded. The Registered Dietitian (RD) confirmed that the freezer-burned meat could potentially harbor bacteria and cause food poisoning. Additionally, a foam cup with a staff member's name but no date was found in the walk-in refrigerator, improperly stored alongside resident food, which could lead to cross-contamination. Further inspection revealed an open yogurt container in the walk-in refrigerator without an open date, which the DSS and RD agreed should have been labeled to prevent serving expired food to residents. In the storage pantry, a bin of oats lacked both an opened and received date, contrary to the facility's policy, which could result in residents consuming expired oats. These lapses in labeling and storage practices were acknowledged by the DSS and RD, who emphasized the importance of proper labeling to prevent foodborne illnesses. In resident rooms, items brought by family members, such as cookies, snacks, and sodas, were found without labels indicating the date received or opened. This oversight was noted in the rooms of two residents, one with conditions including hypertension, Alzheimer's disease, and diabetes, and another with Parkinson's disease and malnutrition. Staff interviews confirmed that these items should have been labeled to prevent residents from consuming expired food, which could lead to health issues. The facility's policy requires food brought by family members to be labeled with the resident's name and a 'use by' date to ensure safety.
Failure to Ensure Resident Privacy During Medical Treatments
Penalty
Summary
The facility failed to ensure privacy and confidentiality for two residents during medical treatments. In the first instance, a Licensed Vocational Nurse (LVN) did not pull the curtains or close the door while performing a blood glucose test and administering insulin to a resident. This resident, who was cognitively intact, was exposed to the view of anyone passing by the open doorway, compromising his privacy during the procedure. In the second instance, the same LVN administered eye drops to another resident without pulling the curtains, allowing the resident's roommate to observe the procedure. This resident had severe cognitive impairment, but the lack of privacy during the medication administration was still a concern. The LVN acknowledged that the curtains should have been drawn to provide privacy. Interviews with other staff members, including another LVN, a Certified Nursing Assistant (CNA), and the Director of Nursing (DON), confirmed the importance of maintaining resident privacy during care. The facility's policies and job descriptions also emphasized the need for privacy and confidentiality, highlighting a failure to adhere to these standards during the observed incidents.
Improper Use of Hoyer Lift Sling Causes Resident Discomfort
Penalty
Summary
The facility failed to provide services that met professional standards of quality of care for a resident when a Hoyer lift sling was used incorrectly during a transfer from a wheelchair to a bed. The resident, who had conditions including muscle contracture, generalized weakness, and abdominal pain, experienced pain and discomfort during the transfer. The Certified Nursing Assistants (CNAs) used the shortest hooks near the resident's shoulders and the longest hooks near the legs, causing the resident to be lifted in a sitting position, which was contrary to the proper procedure for transferring from a chair to a bed. Interviews with the CNAs and other staff revealed a lack of awareness and adherence to the correct procedure for using the Hoyer lift sling. The Director of Staff Development and a Licensed Vocational Nurse confirmed that the staff should have positioned the resident in a more reclined position during the transfer to the bed. The Owner's Manual and Instruction Guide for the Hoyer lift also indicated the need for a reclined position during such transfers. The Director of Nursing acknowledged that the resident should not have experienced discomfort and that the manufacturer's guidelines should have been followed.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure accurate labeling and storage of medications, which was observed during a survey. One of the medication carts had two out of 199 pill packets without visible expiration dates. The Licensed Vocational Nurse (LVN) acknowledged that the expiration dates should have been visible and stated that if they were not, the medication should not be administered. The Director of Nursing (DON) confirmed that labeling medications correctly was a facility policy and emphasized the importance of visible expiration dates to prevent administering expired medications, which could lose potency and be ineffective. Additionally, the facility did not label the inside containers of boxed medications with resident information. During observations, it was noted that seven boxed medications lacked labels on the medication containers inside. LVNs stated that if the medication came out of the unlabeled box, it could be given to the wrong resident, leading to medication errors. The DON reiterated the importance of labeling medication containers with the resident's name to prevent harm. The facility also failed to maintain proper storage temperatures for medications. One of the medication refrigerators was observed to be below the required temperature range, which could damage the medications and make them unsafe for use. The Minimum Data Set Nurse (MDSN) and the Assistant Director of Nursing (ADON) acknowledged the issue and stated that the pharmacist should be consulted if the temperature was out of range. The DON emphasized that maintaining the appropriate temperature range was crucial to preserving medication potency.
Failure to Ensure Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure that 56 sampled residents received food at a safe and appetizing temperature. On the day of the observation, the Dietary Cook (DC) did not check the temperature of the food on the steam table before serving it to the residents. The DC placed trays of lasagna and other food items on the steam table without verifying their temperatures, which is a critical step to ensure food safety and palatability. During interviews, the DC admitted to not checking the temperatures and acknowledged the absence of temperature logs for the steam table items. The Dietary Services Supervisor (DSS) confirmed that the DC should have checked the temperatures to ensure the food was warm and safe for consumption. The Registered Dietitian (RD) also emphasized the importance of checking food temperatures to prevent bacterial growth and ensure food safety. The facility's policy on meal preparation and service, dated 2011, specifies that food items like casseroles and vegetables should be held at a minimum temperature of 140 degrees Fahrenheit. The failure to adhere to this policy had the potential to result in residents being served cold food, which could lead to decreased food intake and weight loss, as well as an increased risk of foodborne illnesses.
Failure to Maintain Safe Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to maintain essential equipment in a safe operating condition, specifically the medication refrigerator in the B-wing. During an observation, the refrigerator's temperature was recorded at 32 degrees Fahrenheit, which is below the acceptable range for storing medications. The Minimum Data Set Nurse (MDSN) confirmed that such a low temperature could damage medications, making them unsafe for resident use. The Temperature Log indicated that temperatures below 36 degrees Fahrenheit are too cold, and the MDSN acknowledged the risk of medication damage if stored at such temperatures. The Assistant Director of Nursing (ADON) stated that the Infection Prevention Nurse was responsible for monitoring the refrigerator temperatures. If the temperature was out of range, the protocol was to notify maintenance and consult the pharmacist. The Maintenance Director (MAINTD) later observed the refrigerator temperature at 41 degrees Fahrenheit after adjusting the control knob, indicating that the door being open could have caused a temporary rise in temperature. However, the MAINTD admitted that the refrigerator was not regularly checked for maintenance, and there was no maintenance log for it. Interviews with staff revealed that the B-wing medication refrigerator had issues, such as leaking water, and required defrosting. Medications were moved to another refrigerator as a precaution. The MDSN consulted with a pharmacist, who advised checking medications for crystallization before use. The facility's job descriptions for maintenance staff emphasized the importance of regular inspections and preventative maintenance, but these were not implemented for the medication refrigerators, leading to the deficiency.
Failure to Implement Pain Management Care Plan
Penalty
Summary
The facility failed to implement a care plan for a resident experiencing chronic pain, particularly in relation to pre-medicating with an analgesic before physical therapy sessions. The resident, who was admitted with conditions including generalized abdominal pain, poly-osteoarthritis, muscle weakness, and muscle contractures, reported experiencing significant pain during transfers and physical therapy. Despite the care plan specifying the administration of pain medication 30 minutes prior to treatments, this intervention was not followed, resulting in unmanaged pain for the resident. Interviews with staff revealed a lack of adherence to the care plan. A Licensed Vocational Nurse (LVN) admitted to not administering the prescribed analgesic before physical therapy, stating she was unaware of this requirement in the care plan. The Certified Nursing Assistant (CNA) confirmed that the resident frequently complained of pain, which was reported to the nursing staff. The Minimum Data Set (MDS) Nurse Coordinator acknowledged that the care plan was not followed, which could hinder the resident's participation in physical therapy due to unmanaged pain. The Director of Nursing (DON) and other staff members emphasized the importance of following care plans to ensure proper resident care. The Physical Therapy assistant also noted the resident's complaints of pain during transfers and the necessity of premedication for effective therapy sessions. The facility's policy on care plans highlighted the need for comprehensive, person-centered plans with measurable objectives, which were not adhered to in this case, leading to inadequate pain management for the resident.
Failure to Administer Pain Medication Before Physical Therapy
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 3, who was not administered analgesia as per his care plan before undergoing physical therapy. This oversight resulted in Resident 3 experiencing significant pain during transfers using a Hoyer lift and during physical therapy sessions. Resident 3, who suffers from generalized abdominal pain, poly-osteoarthritis, muscle weakness, and contractures, reported daily pain, particularly during transfers and physical therapy, which was not adequately addressed by the facility staff. Observations and interviews revealed that Resident 3 frequently expressed pain, especially during transfers and physical therapy. Despite having a care plan that specified the administration of PRN analgesia 30 minutes before treatments, this was not followed. Licensed Vocational Nurse (LVN) 1, who was responsible for Resident 3's care three days a week, admitted to not administering the PRN analgesic prior to physical therapy, as she was unaware of this requirement in the care plan. The failure to administer pain medication as outlined in the care plan was acknowledged by multiple staff members, including the MDS Nurse Coordinator and the Director of Nursing, who confirmed that the care plan was not followed. The facility's policies and procedures for pain management and care plans emphasize the importance of assessing and addressing pain to ensure residents' well-being. However, in this case, the staff did not adhere to these protocols, resulting in Resident 3 experiencing unnecessary pain. The Director of Nursing and other staff members recognized that the failure to manage Resident 3's pain according to the care plan could negatively impact his participation in physical therapy and overall condition.
Failure to Follow Physician's Dietary Order for Resident
Penalty
Summary
The facility failed to adhere to a physician's dietary order for a resident, identified as Resident 14, who was supposed to receive a small portion diet. On a specific date, during a tray line observation in the kitchen, it was noted that the dietary staff used a number 8 scoop size instead of the required number 10 scoop size for small portions. This discrepancy was confirmed by the Dietary Services Supervisor, who acknowledged that the incorrect scoop size was used, potentially leading to Resident 14 receiving more calories than prescribed. Resident 14, who was cognitively intact with a BIMS score of 15, had multiple medical diagnoses including hypertension, type 2 diabetes, anxiety disorder, gastritis, gout, and irritable bowel syndrome. The facility's policy on food preparation emphasized the importance of portion control to meet nutritional specifications, yet the dietary staff failed to follow the physician's order for a small portion, as indicated in the resident's order listing report. The Registered Dietitian also confirmed that the correct scoop size was not used, which could have resulted in weight gain for the resident.
Failure to Follow Resident Meal Preferences
Penalty
Summary
The facility failed to adhere to a resident's meal preferences, which were crucial due to her medical conditions. The resident, who had diverticulitis and protein-calorie malnutrition, was served chicken with skin and beets, despite her documented dislikes and dietary restrictions. This oversight was observed during a meal service, where the resident expressed her dissatisfaction and concern that consuming such foods could exacerbate her condition. The Registered Dietitian confirmed that the resident's preferences should have been followed to prevent malnutrition. Interviews with facility staff, including a CNA, the Director of Staff Development, an LVN, and the Director of Nursing, revealed a lack of proper checks and communication regarding meal preferences. The CNA and DSD indicated that nurses were responsible for ensuring meal accuracy, but CNAs could also verify trays. The LVN and DON acknowledged the importance of following dietary orders, especially given the resident's medical history. A review of the facility's policy on therapeutic diets emphasized the need to align meals with residents' informed choices and treatment goals.
Incomplete Antipsychotic Consent Forms for a Resident
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented in accordance with accepted professional standards of practice for a resident, identified as Resident 8. Specifically, the antipsychotic consent forms for Resident 8 were incomplete, as the physician signatures on the forms dated March 5 and September 4 were not dated. This oversight put Resident 8 at risk of receiving antipsychotic medication without being informed of the risks and benefits. The Director of Nursing (DON) acknowledged that the consent forms should have been dated by the physician and that the consents were not valid without a dated signature. The DON also stated that the Medical Records Department was responsible for verifying the completion of consents, and nurses were expected to verify consents before administering medications. During the review, it was noted that Resident 8 had a severe cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of three, indicating a significant need for careful consent procedures. The Licensed Vocational Nurse (LVN) confirmed that the antipsychotic consents were incomplete without the physician's dated signature, emphasizing the importance of knowing when consent was obtained. The facility's job description for the Medical Records Technician and the policy on Informed Consent both highlighted the responsibility to ensure records are accurate and complete, and that informed consent must be verified before administering psychotropic medications.
Infection Control Breach in Kitchen
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a contractor technician (CT) who did not wash his hands upon entering the kitchen. This incident was observed on 10/25/24 at 8:55 a.m. when the CT proceeded to scoop ice from the ice machine without prior handwashing. During an interview, the CT acknowledged the importance of handwashing to prevent cross-contamination and admitted that he should have washed his hands before handling the ice. This lapse in protocol had the potential to cause cross-contamination and foodborne illnesses among the 56 residents, staff, and visitors who consumed ice from the machine. Interviews with the Dietary Services Supervisor (DSS) and the Registered Dietitian (RD) further confirmed the deficiency. Both the DSS and RD stated that the CT should have washed his hands upon entering the kitchen to prevent the spread of germs and bacteria. The facility's policy and procedure on sanitation and infection control, dated 2011, also indicated that handwashing should occur before starting work in the kitchen. Additionally, a professional reference on food contamination and foodborne illness prevention highlighted inadequate handwashing as a contributing factor to foodborne illnesses. This incident underscores a failure to adhere to established infection control protocols, potentially compromising the safety and health of residents and others in the facility.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum required space of at least 80 square feet per resident in multiple resident rooms. During the survey conducted from October 22 to October 28, 2024, it was observed that 22 rooms, each housing two residents, measured only 154 square feet, which is below the required space per resident. This deficiency was identified during an environmental tour with the Maintenance Supervisor, who confirmed the room measurements. Despite the deficiency, interviews with staff and residents indicated that there were no complaints or issues regarding room size, privacy, or space for care. Certified Nursing Assistant 7, who has worked at the facility for seven years, stated that room sizes had not been an issue, and there was adequate space for care and storage. Similarly, a resident interviewed expressed no concerns about room size, privacy, or storage. Observations during the survey period noted that the rooms provided reasonable privacy, adequate storage, and sufficient space for nursing care and resident ambulation. The report suggests that the waiver for room size requirements should continue, as it does not adversely affect the health and safety of residents.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Selma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rolling Hills Care Center | 0.7 mi | ★★★★★ | 21 | 0 |
| Kingsburg Center | 3.6 mi | ★★★★★ | 3 | 0 |
| Fowler Care Center | 5.2 mi | ★★★★★ | 2 | 0 |
| Vineyards At Fowler | 5.7 mi | ★★★★★ | 25 | 0 |
| Palm Village Retirement Comm. | 8.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.