Bethany Woods Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Bethany Woods Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF602Apr 2, 2026

  Based on record reviews, and interviews with the police detective, pharmacy consultant, physician and staff, the facility failed to protect the residents' right to be free from misappropriation of multiple non-narcotic medications when Nurse #1 was found with a bag of prescribed medications during a traffic stop. This deficient practice affected 16 of 16 residents reviewed for misappropriation (Residents #2, #10, #31, #37, #60, #68, #78, #86, #88, #121, #122, #123, #124, #125, #126, and #127).The findings included: A review of the facility's policy entitled Abuse, Neglect, Misappropriation and Exploitation dated August 2019 read in part . […]

• No harm, potential for more than minimal, patternF761Apr 2, 2026

  Based on observations and staff interviews, the facility failed to secure medications left on top of and in an unattended unlocked medication cart (400 hall medication cart) and failed to remove one (1) bottle of expired eye drops, label an Ozempic insulin pen with the name of the specific resident for whom it was prescribed and the date it was opened, and stored an unopened insulin pen in the medication cart (800 hall medication cart). This was for 2 of 3 medication carts observed for medication storage (400 hall and 800 hall medication cart). The findings included: 1. A continuous observation of an unattended medication cart on the 400 hall was made on 4/2/26 from 12:35 PM until 12:38 PM. […]

• No harm, potential for more than minimal, patternF677Dec 19, 2024

  Based on record reviews, observations and interviews with residents and staff, the facility failed to provide routine hair trimming. This was for 4 of 6 residents reviewed for activities of daily living (ADL) (Residents #36, # 50, #53, and #77). The findings included: 1. Resident #36 was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was cognitively intact. During an interview and observation with Resident #36 on 12/18/24 at 10:00 AM, he expressed that he would like to have his hair cut as it was longer than he liked to wear it. He explained he had not been able to get his hair cut in four months since the facility no longer had anyone available to provide this service. […]

• No harm, potential for more than minimal, patternF760Dec 19, 2024

  Based on record reviews, and Nurse Practitioner, Medical Director, family member, and staff interviews, the facility failed to prevent significant medication errors when Nurse #1 administered medications to Resident #23 prescribed for Resident #240 which included Eliquis (used to prevent blood from clotting), buspirone (used to treat anxiety disorders), gabapentin (used to treat epilepsy), isosorbide (used to treat high blood pressure), metoprolol (used to treat high blood pressure), spironolactone (used to treat high blood pressure), citalopram (used to treat depression). In addtion Resident #4 was administered medications prescribed to Resident #191 which included Aricept (used to treat dementia), Lexapro (used to treat depression) and Tramadol (used to treat pain). […]

• No harm, potential for more than minimal, patternF812Sep 1, 2023

  Based on observation and staff interview, the facility failed to maintain a clean floor and walls in the dry food storage room for 1 of 2 dry food storage rooms observed (the emergency dry food storage area). Findings included: On 08/28/23 at 9:34 am an initial observation of the kitchen, including the emergency dry food storage room was conducted. The dry food storage room floor and walls had black soiling all over them (entire floor and wall without shelves) as well as the front of the ice machine. The inside of the ice machine was clean and had ice. Concurrent interview with the Dietary Manager was conducted. He stated the floor had not been cleaned in a couple of days and the black was soil not aging of the floor tile and the front of the ice machine had splatter. […]