Bethany Home

In the surveyor’s words

From the most serious findings on record at Bethany Home, in the surveyor’s own words.

• Immediate jeopardy, patternF689Dec 14, 2021

  Based on observation, clinical record review, and staff interview, the facility failed to provide adequate supervision and failed to implement safety interventions to prevent an elopement for 1 of 12 residents sampled (Resident #43) for supervision. The resident had a history of leaving the unit without staff knowledge. The resident exited the second floor elevator and then exited the ground floor ambulance door without staff knowledge. Staff F found Resident #43 in his pajamas, bath robe, and slippers on the street behind the facility. Resident #43 stated he was lost. The failure resulted in Immediate Jeopardy to the health, safety, and security of the residents. The facility identified 17 residents as independently mobile and cognitively impaired. […]

• Actual harm, isolatedF689Jun 18, 2026

  Based on observation, clinical record review, document review, procedure review, manufacturer use manual, and staff interview, the facility failed to ensure Certified Nursing Assistants (CNAs) locked wheelchair brakes during pivot and full body mechanical lift transfers for 1 of 4 residents reviewed (Resident #23). This failure resulted in Resident #23 falling and sustaining a left ulna fracture (a break in the ulna is one of the two long bones in the forearm (running along the pinky-finger side). The facility identified a census of 63 residents.Findings include:1.The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #23 exhibited a long/short memory problem, and had severely impaired daily decision-making ability. Resident #23 did not exhibit behaviors. […]

• No harm, potential for more than minimal, isolatedF658Mar 30, 2023

  Based on observation, resident record review, and staff interview, the facility failed to administer medications in a means that care and medication administration services had been provided according to accepted standards of clinical practice within a locked Memory Care Unit and secondly after a resident had received an ophthalmology procedure and returned to the facility with new orders. The facility reported a census of 67. Findings include: 1. A continuous observation had taken place on 3/28/23 from 8:14 AM to 8:20 AM. On 3/28/23 at 8:14 AM the dietary staff entered the Memory Care Unit with the steamer cart server to provide residents breakfast. […]

• No harm, potential for more than minimal, isolatedF812Mar 30, 2023

  Based on observation, interview, and policy review the facility failed to have dietary male staff wear beard restraints, according to the current standards of practice per the Food Code of the FDA (Food and Drug Administration), food service staff must wear hair restraints (e.g., hairnet, and/or beard restraint) to prevent hair from contacting food while they were working in the kitchen to prevent hair from contacting food while cooking, preparing and assembling food for all facility residents. The facility reported a census of 67 residents. Findings include: On 3/27/23 at 9:28 AM, an initial tour of the kitchen was conducted with the Dietary Manager. During observations the Dietary Manager introduced a male cook, Staff A, who wore a hairnet and facial mask however no beard restraint. […]

• No harm, potential for more than minimal, isolatedF658Dec 14, 2021

  Based on observation, record review, policy review, and staff interview, the facility failed to administer medications within professional standards for 1 of 12 residents observed (Resident #24) during medication administration. The facility reported a census of 61. Findings include: Observation during medication pass on 12/7/21 at 12:24 PM, Staff I, Certified Medication Aide, placed Resident #24's medication cup on his/her tray table. The medication cup contained [MEDICATION(S)] 40 mg and Dairy Relief 3000 units. Staff I stated she was going to lunch and would have Staff J check on the resident to make sure she took her medications as she likes to take them with food. Staff I exited Resident #24's room at 12:33 PM and closed the door. […]