Bethel Manor

In the surveyor’s words

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

• Actual harm, isolatedF689Mar 8, 2022

  Based on observation, interview, and record review, the facility failed to provide supervision to prevent falls, resulting in hip fractures; utilized alarms for supervision; and failed to correctly place an alarm, for 3 of 3 residents reviewed for falls (Residents B, C, D). Findings include: 1. On 3/7/22 at 9:20 A.M., during the initial tour, the Director of Nursing (DON) indicated Resident C had recently fallen. The resident had sustained a fractured hip. Resident C was observed lying in bed at that time, with his eyes closed. The clinical record of Resident C was reviewed on 3/7/22 at 1:35 P.M. […]

• No harm, potential for more than minimal, patternF550Mar 16, 2026

  Based on observation, interview and record review, the facility failed to ensure residents privacy. Staff did not knock on resident doors before entering to deliver meal trays. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Finding includes: The following was observed during the delivery of meal trays at supper on 3/12/26:At 5:06 p.m., CNA 3 was observed to enter room [ROOM NUMBER] with a meal tray without knocking or announcing himself. At 5:07 p.m., CNA 2 was observed to enter room [ROOM NUMBER] with a meal tray without knocking or announcing herself. At 5:10 p.m., CNA 2 was observed to enter room [ROOM NUMBER] with a meal tray without knocking or announcing herself. […]

• No harm, potential for more than minimal, patternF812Aug 22, 2025

  Based on observation, interview, and record review, the facility failed to store and prepare food under sanitary conditions during 3 of 3 kitchen observations. Food was not labeled correctly, expired food was not disposed of, hairnets were not worn properly, and staff placed their fingers in their mouth during food service. (Main Kitchen, Cottage Kitchen, Dietary [NAME] 9)Findings include: 1. On 8/19/25 at 8:55 A.M., the following was observed during the initial tour of the Main Kitchen:In large reach-in refrigerator:1 gallon jug of coleslaw, dated 7/2 with a best by date of 6/5/25.On the spice rack at the preparation table:2 bottles of chili pepper with no open date1 bottle of lemon pepper with no open date1 bottle of sage with no open date1 bottle of pepper with no open date1 bottle of… […]

• No harm, potential for more than minimal, patternF677Jul 26, 2024

  Based on interview and record review, the facility failed to ensure residents requiring assistance with Activities of Daily Living (ADLs) received adequate assistance with showering/bathing for 4 of 4 residents reviewed for dependent ADL care. (Resident 28, Resident 37, Resident 57, Resident 6) Findings include: On 7/23/24 at 3:10 P.M., multiple Resident's attending the Resident Council meeting voiced concern of not receiving routine showers and/or complete bed baths as scheduled. 1. On 7/23/24 at 10:12 A.M. Resident 28's clinical record was reviewed. […]

• No harm, potential for more than minimal, patternF688Jul 26, 2024

  Based on interview and record review, the facility failed to ensure residents with limited range of motion or mobility received services to maintain or improve mobility for 4 of 4 residents reviewed for restorative therapy. (Resident 6, Resident 28, Resident 52, Resident 55) Findings include: 1. On 7/23/24 at 10:12 A.M. Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and polyosteoarthritis. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 5/8/24, indicated Resident 28 was severely cognitively impaired and required substantial assistance from staff for toileting, bathing, and transfers. […]