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, widespreadF812Mar 7, 2022

  Based on observation, interview, and record review, the facility did not follow proper sanitation in accordance with professional standards for food service safety. This had the potential to affect all 67 residents. The facility did not consistently check temperatures of facility warewashing machines and failed to [MEDICATION(S)] when temperatures were below minimum wash and rinse temperatures specified for proper sanitization of dishes. Additionally, on 2/23/22, the facility identified an outbreak of Gastrointestinal Illness with the first case that began on 2/19/22. […]

• Actual harm, isolatedF689Oct 27, 2025

  Based on staff interview and record review, the facility did not ensure the resident environment was as free of accident hazards as possible for 1 Resident (R) (R1) of 3 sampled residents. R1 required an EZ stand mechanical lift with the assistance of 2 staff for transfers. On 9/25/25, R1 slipped from the EZ stand, was lowered to the floor, and suffered a left clavicle fracture when agency Certified Nursing Assistant (CNA)-C transferred R1 alone. In addition, agency Registered Nurse (RN)-D did not transfer R1 to the emergency room (ER) per R1's request because RN-D did not know how to complete the paperwork. The facility identified deficient practices but did not provide education to agency staff who worked since the incident. […]

• Actual harm, isolatedF686Apr 8, 2021

  Based on observations, record review and staff interviews, the facility did not ensure each resident received necessary treatment to prevent and heal pressure injuries for 5 Residents (R) (R15, R64, R19, R14, and R5) of 18 sampled residents. R15 was admitted to the facility without a pressure injury (PI) and was identified to be at risk for development of pressure injuries. The facility identified that R15 developed avoidable bilateral (affecting both sides) heel Stage 2 PIs on 2/23/2021 that deteriorated. […]

• Actual harm, isolatedF867Apr 8, 2021

  Based on observation, record review and staff interview, the facility did not identify issues to which quality assessment and assurance activities are necessary, or develop and implement appropriate plans of action to correct identified quality deficiencies. This was evidenced by the number of facility acquired pressure injuries, which affected 5 Residents (R) ( R15, R64, R19, R14, and R5) who were at risk for PIs and who developed facility-acquired PIs. The facility's Quality Assurance & Performance Improvement Plan (QAPI), dated 7/9/15 and reviewed yearly with the latest review date of 3/25/21, includes, in part: Purpose Statement: The purpose of QAPI in our organization is to take a proactive approach to continually improving the way we care for and engage with our clients, caregiver,… […]

• No harm, potential for more than minimal, widespreadF880Apr 8, 2021

  Based on staff interview and record review, the facility did not ensure their infection control program included a system of surveillance designed to identify infections and prevent the spread of infections such as COVID-19. This had the potential to affect all 78 residents in the facility. The facility did not have a process in place to ensure visitors entering the facility were properly screened by staff members. Surveyors entered the building and had to seek out staff members who were working the unit to screen the Surveyors when they entered the building. Education on visitor requirements was sent to resident representatives by email with no way to verify if resident representative received the education. […]