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.”