Bethany Skilled Nursing Facility

In the surveyor’s words

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

• Actual harm, isolatedF656Sep 26, 2024

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose comprehensive plan of care indicated he/she required the use of a Hoyer lift (mechanical mobility aid that supports a person's body weight to allow movement from one surface to another) with assistance of two staff members for all transfers, and that staff should reapproach him/her if he/she became combative with care, the Facility failed to ensure staff implemented and followed interventions in his/her care plan, when on 8/22/24, while waiting to be transferred back to bed, Resident #1 became agitated, and per Certified Nurse Aide (CNA) #1, she lifted Resident #1 up from his/her wheelchair with a Hoyer lift to relieve pressure from Resident #1's buttocks, however CNA #1 did so, without having… […]

• Actual harm, isolatedF689Sep 26, 2024

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the use of a Hoyer lift (mechanical mobility aid that supports a person's body weight to allow movement from one surface to another) with assistance of two staff members for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety and prevent an incident/accident resulting in multiple injuries, when on 08/22/24, Certified Nurse Aide (CNA) #1 initiated a Hoyer lift transfer with Resident #1 from his/her wheelchair, without another staff member present to assist her, and Resident #1 slid forward in the Hoyer lift pad and fell forward onto the floor. […]

• Actual harm, isolatedF686Oct 17, 2022

  Based on policy review, record review, and interview, the facility failed to ensure its staff provided the appropriate care and services related to a pressure ulcer for one Resident (#77) out of two applicable sampled residents. Specifically, the facility failed to ensure its staff regularly measured the wound and re-assessed the effectiveness of the wound treatment, resulting in a hospitalization for surgical debridement (removal of devitalized (dead) tissue). Findings include: Review of the facility's policy for Skin Assessment and Decubitus Prevention, dated April 2016, indicated the following: -Measure wounds weekly and document size, depth, description and drainage. […]

• No harm, potential for more than minimal, isolatedF641Jun 9, 2026

  Based on observation, record review and interview the facility failed for two Residents (#69 and #25), out of a total sample of 20 residents, to ensure the Minimum Data Set (MDS) assessments accurately reflected the Residents status. Specifically:For Resident #69 the facility staff failed to ensure the MDS assessment accurately reflected the presence of a Moisture Associated Skin Damage (MASD) wound, andFor Resident #25 the facility staff failed to ensure the MDS assessment accurately reflected the Resident was receiving hospice care services. Findings include:1. […]

• No harm, potential for more than minimal, isolatedF686Jun 9, 2026

  Based on observations, record review and interview, the facility failed to ensure Residents at risk for developing pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new pressure ulcers from developing for one Resident (#54) out of a total sample of 20 Residents. Specifically, for Resident #54, the facility failed to ensure that the air mattress was set to the correct setting as indicated by the physician's order.Findings include:Review of the facility policy titled Alternating Pressure Air Mattress, dated and revised 11/20/21, indicated the following:- Policy: To maintain adequate circulation, relieve pain due to pressure and aid in healing and/or prevention of pressure ulcers.- Procedure: Verify MD order and settings… […]