Bethany Center for Rehabilitation and Healing LLC

In the surveyor’s words

From the most serious findings on record at Bethany Center for Rehabilitation and Healing LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Apr 11, 2025

  Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 4 of 19 staff members (Certified Nursing Assistant (CNA) F, G, H and Activity Assistant E) failed to perform hand hygiene and handled food with barehand during dining observations, and when 1 of 2 staff (Dietary [NAME] I) failed to perform proper hand hygiene when preparing meal trays. The facility had a census of 166 with 166 of those residents receiving a tray from the kitchen. The findings include: 1. […]

• No harm, potential for more than minimal, isolatedF686Aug 6, 2026

  Based on facility policy review, medical record review, and interview, the facility failed to ensure the care and services for the use of a Negative Pressure Wound Therapy (NPWT) (a machine used on a wound to promote healing) machine and wound treatments were completed as ordered by the Physician for 3 of 7 (Resident #2, #55, and #147) sampled residents reviewed for pressure ulcers/wounds. The findings include: 1. Review of the facility policy titled, WoundCare (Wound Care), dated 10/7/2024, revealed .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.Verify that there is a physician's order for this procedure.The following information should be recorded in the resident's medical record.The type of wound care given.The date and time the wound… […]

• No harm, potential for more than minimal, isolatedF578Apr 11, 2025

  Based on policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to develop an Advance Directive for 4 of 33 sampled residents (Resident #21, #71, #77 and #108) reviewed for Advance Directives. The findings include: 1. Review of the facility policy titled Advance Directives, revised on 9/2022, revealed .The resident has the right to formulate an advance directive .Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. […]

• No harm, potential for more than minimal, isolatedF730Apr 11, 2025

  Based on policy review, Certified Nursing Assistant (CNA) training record review, and interview, the facility failed to ensure 23 of 23 CNAs (CNA G, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, and EE) employed for a full year received at least 12 hours of in-service training. The findings include: 1. Review of the facility's policy titled In-Service Training, Nurse Aide, dated august 2022, revealed .all Personnel are required to participate in regular in-service education .Annual in-service: Ensure the continuing competence of nurse aides; are no less than 12 hours per year . 2. Review of the Inservice Training Hours revealed: a. CNA G had a hire date of 3/30/2024 and had only competed 8.50 in-service hours from 4/3/2024 -present. b. […]

• No harm, potential for more than minimal, isolatedF761Apr 11, 2025

  Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 4 staff members (Registered Nurse (RN) II) left the medication unattended and out of sight at the bedside in Resident #10's room. The findings include: 1. Review of the facility's policy titled Medication Labeling and Storage, dated 5/19/2023, revealed .trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others . 2. Observation on 4/2/2025 at 3:40 PM, revealed Register Nurse (RN) II left the medication on the over bed table in Resident #10's room. […]