LAKEWOOD, CO-BETHANY NURSING AND REHAB CENTER

The Department of Health & Human Services conducted an inspection of the facility. The following highlighted decencies listed below were found in a public survey.

Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Based on observations and interviews, the facility failed to ensure care for residents was provided in a
manner and in an environment that maintained or enhanced the residents’ dignity and respect in full
recognition of their individuality for one (#15) of one resident reviewed for dignity out of 22 sample residents.

Specifically, the facility failed to ensure staff were not using their personal cell phones while providing
incontinence care, assisting a resident with eating and while in resident care areas. The use of employee cell phones during care resulted in Resident #15 reporting anxiety, humiliation, embarrassment and frustration.

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Based on observation, interview, and record review the facility failed to ensure three (#14, #20 and #22) of three residents reviewed for dementia care of 22 sample residents, received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being.

Resident #14 was admitted to the facility for long term care on 5/25/23 with diagnoses of Alzheimer’s disease, senile degeneration of the brain, anxiety disorder, depressive episodes, and cognitive communication deficit. The resident required supervision with one person physical assistance with walking in the room and corridors. The resident required extensive one person assistance with dressing. Since admission on 5/25/23 the resident had increasing wandering, agitation and physically aggressive behaviors.

Due to the facility failures, Resident #14 wandered into other residents’ rooms. The facility failed to determine and prevent triggers that caused agitation and physical aggression toward other residents. The facility failed to maintain the ability for the resident to communicate with staff with the translator machine that required the internet to operate. These failures resulted in Resident #14 was involved in four resident to resident altercations with three other residents, one resident twice over an eight day period.

Additionally, the facility failed to implement personalized interventions for Resident #20 and Resident #22, who wandered into other resident rooms.

Cross-reference F600 the facility failed to prevent resident to resident altercations by implementing appropriate safety measures for Residents #14 and #20.

Allow residents to easily view the nursing home’s survey results and communicate with advocate agencies.

Based on observations, record review and interviews, the facility failed to ensure residents, family members and legal representatives had full access to review the results of the facility’s most recent survey findings that included the survey results, certifications, complaint investigations and plans of correction in effect for the preceding three years.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Based on interviews, record review, and observations, the facility failed to protect six of nine residents reviewed out of 22 sample residents (#14, #20, #21, #15, #16, and #17) from incidents of resident-to-resident abuse and neglect.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#10) of three residents reviewed for professional standard out of 22 sample residents.

Specifically, the facility failed to ensure Resident #10 received the care and services to treat a surgical wound and prevent the development of severe cellulitis (skin infection).

Provide safe, appropriate pain management for a resident who requires such services

Based on observations, interviews and record review, the facility failed to manage pain in a manner
consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences for two (#15 and #10) of three residents reviewed out of 18 sample residents.

Resident #15 admitted on [DATE] with chronic pain and neuralgia (pain due to damaged or irritated nerves, neuritis (inflammation of nerves due to injury or infection). According to record review and interviews, the facility failed to ensure the Resident #15’s Oxycodone pain medication was available on three separate
occasions resulting in increased pain.

Additionally, the facility failed to administer Resident #10 the correct pain medication per physician order after a surgical procedure.

Observe each nurse aide’s job performance and give regular training.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews for five of eight staff reviewed.

Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA), #13, CNA #14, CNA #15, CNA #9 and CNA #16.