Bethany Health & Rehabilitation Center LLC

Based on observation, medical record review, review of the facility Resident Agreement, policy review and interview, the facility failed to ensure medications were stored in a secured manner. This affected Resident #20 and had the potential to affect 19 (Residents #2, #3, #5, #6, #7, #8, #12, #13, #15, #16, #17, #18, #19, #21, #22, #23, #24, #26 and #27) of 26 additional residents residing on the unit identified as being independently mobile.

Findings include:

1. On 10/14/25 at 9:04 A.M., during the tour with Administrative Assistant #50, the nursing station door was unlocked. A cabinet was unlocked and contained cards of medications which were unattended. Administrative Assistant #50 verified there were unlocked/unattended medications in the nursing station. Administrative Assistant #50 stated she would get the key and walked away. Upon her return, Administrative Assistant #50 was carrying a set of keys she believed contained the nursing station key but acknowledged she was not a nurse and should not have a key to the nursing station if medications were stored there. The key to the nursing station was not located on the key ring.

On 10/14/25 at 9:10 A.M., Registered Nurse (RN) #55 indicated she was unaware there were medications in the unlocked cabinet when she left the door unlocked.

The facility identified medications in the unlocked cabinets as potassium, metformin (anti-diabetic), spironolactone (diuretic), albuterol sulfate (bronchodilator), metronidazole gel (antibiotic), docusate (stool softener/laxative), albuterol inhaler, phenergan (antihistamine), cefdinir (antibiotic), ondanestron (anti-emetic), pantoprazole (proton pump inhibitor), metronidazole, metolazone (diuretic), nifedipine (calcium channel blocker), atorvastatin (statin), carvedilol (beta blocker), benzonatate (cough suppressant), prednisone (corticosteroid), amlodipine (calcium channel blocker) and omeprazole (proton pump inhibitor).

RN #55 and Administrative Assistant #50 took turns attempting to locate the key to the nursing station door between 9:05 A.M. and 9:16 A.M. when the key was located.

Review of the facility's Assisted Living Medication Administration Policy (undated) revealed all medications were to be stored in locked cabinets or carts.

The facility identified Residents #2, #3, #5, #6, #7, #8, #12, #13, #15, #16, #17, #18, #19, #21, #22, #23, #24, #26 and #27 as being independently mobile.

2. On 10/14/25 at 9:24 A.M., RN #55 was observed preparing medications for administration to Resident #20. Medications included one tablet of aspirin 81 milligrams (mg), one lotensin (angiotensin converting enzyme inhibitor) 40 mg,, one glucosamine-chondroitin 250/200 , one multi-vitamin, one vitamin C 500 mg , one vitamin D3 50 micrograms (mcg), one senna S (laxative) 8.6 mg-50 mg, and two acetaminophen (analgesic/antipyretic) 500 mg. Prior to taking the medications into Resident #20's room, RN #55 stated protocol was if the resident was not in her room she could leave the medication on the table for later consumption. Resident #20 was not in her room and RN #55 left medication on the table inside her door, pulling the unlocked door shut behind her.

Once RN #55 returned to the medication cart, the practice of leaving unattended medication in an unlocked room was questioned. RN #55 stated she was told the practice was okay for residential care facilities.

Review of Resident #20's self administration of medication assessment dated 06/18/25 revealed a licensed nurse was to administer medication. Resident #20 was unable to open locks and handle medications, was able to recognize hazards of leaving medications unattended and had limited capability to self administer medications.

Review of page 8 of the facility's Resident Agreement revealed if a resident preferred to keep medicine in their room, they were required to have written permission from the attending physician. Any medication kept in the room must always be kept under lock and key.

Based on record review and interview, the facility failed to evacuate residents capable of self-evacuation in at least two fire drills a year on each shift. This finding had the potential to affect all 32 residents residing in the facility.

Findings include:

Review of the fire drills completed from 12/01/21 to 11/30/22 revealed no evidence residents were being evacuated during the drills completed on 12/21/21 on evening shift, 01/11/22 on night shift, 02/28/22 on day shift, 03/31/22 on second shift, 04/13/22 on night shift, 05/18/22 on day shift, 06/14/22 on afternoon shift, 07/11/22 on night shift, 08/30/22 on day shift, and 09/30/22 on afternoon shift.

Interview with the Administrator on 12/13/22 at 2:40 P.M. confirmed that there was no evidence residents were being evacuated during fire drills for at least two of four fire drills conducted on each shift for ten of 12 fire drills completed.