NEW BETHANY

Official classification

Type B

Official code

87468.1(6)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. The following requirement has not been met as evidenced by: LPA observed a long stick blocking Resident 1's screen door and preventing Resident 1 from leaving their bedroom and entering the courtyard, which poses a potetial, health, safety, or personal rights risk to residents in care.

Official plan of correction

Administrator will install alarm/chimes on resident 1's sliding glass door in place of object blocking resident's door.

Deadline recorded: Jul 3, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed scissors, hand pruners, and insect killer in unlocked closest in the activity room. LPA observed cleaning/disinfectant in unlocked utility closet in activity room. LPA observed laundry detergent accessible to residents under the sink in a laundry room.

Official plan of correction

POC Due Date: 03/26/2026 Plan of Correction Administrator will in-service staff and items will be placed in secure location. Verification will be sent to the Dept by POC due date.

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA reviewed R1's centrally stored medication log which did not have a start date for Tamsulosin 0.4MG & Atorvastatin Calciui/40MG.

Official plan of correction

POC Due Date: 03/26/2026 Plan of Correction Staff corrected log while LPA was at the facility. Administrator will have in-service will all staff regarding centrally stored medication log.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed ice machine to have mildew/build up on the inside and hard water build up on the outside, water dispenser in activity room has hard water build up on dispenser tray.

Official plan of correction

POC Due Date: 04/06/2026 Plan of Correction Administrator will discuss with dept leads and in-service staff. Verificaiton will be sent to the Dept by POC due date.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA reviewed staff records and 5 staff records did not have the TB test results in the files.

Official plan of correction

POC Due Date: 04/06/2026 Plan of Correction Administrator will go through files and have proper documentation for TB. Verification will be sent to the Dept by POC due date.

Official classification

Type B

Official code

87412(c)(2)(D)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (D) Number of training hours per subject. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, & record review, the licensee did not comply with the section cited above in 5 out of 5 staff files which poses/posed a potential health, safety or personal rights risk to persons in care. Training documentation does not reflect number of hours conducted on training.

Official plan of correction

POC Due Date: 04/06/2026 Plan of Correction

Official classification

Type B

Official code

87506(b)(17)(A)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal; This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above in 3 out of 7 resident files did not have a pre-admission appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/06/2026 Plan of Correction Nurse will consult with Administrator on policy. Verification of policy will be sent to the Dept by POC due date.

Official classification

Type B

Official code

87458(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above in 2 out of 7 resident physician reports do not have a diagnosis listed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/06/2026 Plan of Correction Nurse will follow up with Administrator to have physician reports proper completed. In-service will be conducted with staff. Verification will be sent to the Dept by POC due date.

Official classification

Type B

Official code

87463(h)(1)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview & record review, the licensee did not comply with the section cited above in 4 out of 7 resident files did not have a current physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/06/2026 Plan of Correction Facility has on site physician who comes weekly. Reports will be updated and verification will be sent to the Dept by POC due date.

Official classification

Type B

Official code

1569.153(d)

Regulation authority

HSC

What the official deficiency says

(d) A written resident personal property inventory is established upon admission and retained during the resident’s stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident’s representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident’s behalf. All additions to an inventory shall be made in ink, and shall be witnessed by the facility and the resident or resident’s representative, and dated. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident, the resident’s family, a responsible party, or a person acting on behalf of a resident. The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory. A copy of a current inventory shall be made available upon request to the resident, responsible party, or other authorized representative. The resident, resident’s family, or a responsible party may list those items which are not subject to addition or deletion from the inventory, such as personal clothing or laundry, which are subject to frequent removal from the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above in 3 out of 7 resident files did not have a written personal property inventory which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/06/2026 Plan of Correction Administrator will in-service staff. Verification of in-service will be sent to the Dept by POC due date.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on observation, interview, & record review the licensee did not comply with the regulation listed above. LPA was provided internal incident reports which were not reported to the Dept.

Official plan of correction

Administrator will make sure reports are submitted within 7 days. Administrator will provide a statement to LPA.

Deadline recorded: Oct 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. Water read at 125.2 degrees Fahrenheit in the common bathroom in the D wing.

Official plan of correction

POC Due Date: 02/26/2024 Plan of Correction Maintenance will come out and check water heaters. Sister Lucinda will follow-up with LPA.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed kitchen in activity room to be unlocked with knife and chemicals accessible to residents.

Official plan of correction

POC Due Date: 02/26/2024 Plan of Correction Room was immediately locked. Facility will remove all items, and send verification to LPA.

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Medication count for R1 was marked as been given and was still in bubble pack.

Official plan of correction

POC Due Date: 02/26/2024 Plan of Correction Facility will conduct an in-service, verification will be sent to LPA.