Bethany Life

In the surveyor’s words

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

• Immediate jeopardy, patternF689Apr 3, 2024

  Based on video observation, interviews, policy, and record review, the facility failed to supervise a resident who needed cues to slow down while eating and provide adequate staff for supervision for 1 out of 5 residents reviewed (Resident #1). Due to the lack of supervision provided to Resident #1 at meals, he was able to eat his dessert very fast. As he started to choke on the dessert, the Certified Nurse Aide (CNA), passed out the meal to the other residents and didn't hear him choking. When the nurse arrived, she alerted the CNA to the situation and took action, due to the consistency of the dessert, the staff couldn't clear the resident's airway. This resulted in his death. This failure resulted in an Immediate Jeopardy situation to the health, safety, and security of the resident. […]

• Actual harm, isolatedF689Mar 5, 2026

  Based on clinical record reviews, staff interviews, resident interview and policy review, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 2 of 4 residents reviewed (Resident #12 and #50). 1. A - On 11/21/25 Resident #12 received a second degree burn from a hot pack which took almost 2 months to heal. 1. B - Resident #12 had an intercepted fall on 1/3/26 which resulted in a left foot injury. 2. On 2/11/26 Resident #50 had a fall due to a staff member letting go of the gait belt. The facility reported a census of 102 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #12 dated 10/22/25 identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. […]

• Actual harm, isolatedF550Feb 13, 2026

  Based on the Resident's Rights policy/procedure, facility incident report, resident, and staff interview the facility failed to treat a resident with respect and dignity in a manner that promoted maintenance or enhancement of his or her quality of life for 1 out of 3 residents reviewed (Resident #1). On 1/18/26 at 2:00 AM, Resident #1 requested not to be checked and changed when Staff A, Certified Nursing Assistant (CNA), came into their room. Staff A, did not grant this request and proceeded to check Resident #1 against their wishes. Staff A put their hand in between Resident #1's thighs to check to see if they soiled their brief. Following the situation, Resident #1 became fearful of Staff A, and caused Resident #1 to have trouble sleeping during the night. […]

• Actual harm, isolatedF689May 7, 2024

  Based on observation, clinical record review, facility policy review, resident, and staff interviews, the facility failed to ensure one (1) of six (6) residents (Resident #6) received adequate supervision to protect against hazards in the environment. On 4/22/24, staff witnessed Resident #6 fall. As Resident #6 fell , the staff assisted her without the use of a gait belt to ambulate (walk) and transfer to the bathroom. Resident #6's fall required a transfer to the local emergency department (ED). The (ED) record revealed Resident #6 received fractures of the 1st, 2nd, 3rd, and 5th proximal phalanges (toes). The facility reported a census of 125 residents. Findings include: 1. […]

• Actual harm, isolatedF689Mar 4, 2024

  Based on observation, clinical record review, staff interviews and policy review, the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 of 2 residents reviewed for falls (Resident #103). The facility reported a census of 117 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #103 had a Brief Interview for Mental Status (BIMS) of 4, indicating severe cognitive impairment. The MDS further documented the resident had diagnoses including fractures and other multiple trauma, hip fracture and non-Alzheimer's dementia. […]