Bethany Home Association

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 21, 2023

  The facility identified a census of 63 residents with three reviewed for accidents and hazards. Based on record review, observation, and interview, the facility failed to provide adequate supervision and failed to respond appropriately to door alarms to prevent an elopement (when a cognitively impaired resident leaves the facility without staff knowledge and /or supervision) for Resident (R)1. On 06/13/23 at approximately 02:05 PM, R1, a severely cognitively impaired resident at high risk for elopement, exited the facility's [NAME] door without staff knowledge and/or supervision. Prior to R1 exiting the building, a family member of another resident exited the same door with their resident and set off the alarm. […]

• No harm, potential for more than minimal, widespreadF945Jun 10, 2026

  Based on record review and interviews, the facility failed to ensure agency staff received the required infection control training. Findings included:- On 06/09/26 at 01:40 PM, a review of the training provided by the facility for agency Certified Nurse Aide (CNA) M, CNA N, CNA O, and CNA P revealed the following:The facility was unable to provide documentation that CNA M had completed infection control training. The facility was unable to provide documentation that CNA N had completed infection control training. The facility was unable to provide documentation that CNA O had completed infection control training. […]

• No harm, potential for more than minimal, widespreadF727Jun 25, 2025

  The facility identified a census of 73 residents. Based on observation, record review, and interview, the facility failed to provide consistent Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. This placed all the residents who resided in the facility at risk of a lack of assessment and inappropriate care. Findings included: - A review of the facility's submitted Payroll Based Journal (PBJ) documented the facility had triggered for the Fiscal Year second quarter (January 1, 2025, to March 31, 2025) for four or more days within the quarter with no RN coverage for eight consecutive hours. Upon review of the facility's working schedule and daily posted staffing revealed that no accounted RN hours were posted for two days (04/27/25 and 05/11/25). […]

• No harm, potential for more than minimal, widespreadF880Aug 14, 2024

  The facility had a census of 70 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by Legionella) and other waterborne pathogens. The facility further failed to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing high-contact care to Resident (R) 36. […]

• No harm, potential for more than minimal, widespreadF868Mar 15, 2023

  The facility identified a census of 60 residents. Based on record review and interview, the facility failed to ensure their Medical Director attended the Quality Assessment and Assurance (QAA) committee meetings at least quarterly. The deficient practice placed the residents of the facility at risk for decreased quality of care. Findings include: - On 03/15/23 at 09:50 AM, Administrative Nurse D provided examples of the QAA committee's performance improvement projects for the past year and sign in sheets of attending staff. The Medical Director of the facility had not attended any of the monthly meetings in 2022 and through the current date, 03/15/23. On 03/15/23 at 09:50 AM, Administrative Nurse D stated the Medical Director had not attended any of the QAA meetings for the past year. […]