Bethlehem Woods Nursing and Rehabilitation

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF761Mar 31, 2026

  Based on observation and record review the facility failed to ensure proper labeling/storage were completed for 3 of 3 medication carts reviewed. This affected 7 of 7 residents reviewed. (Resident 20, Resident 2, Resident 9, Resident 62, Resident 6, Resident 75, and Resident 94) Findings include: During an observation, on 3/26/26 at 11:08 AM, on the 200-hall cart, Resident 20 had an open bottle of liquid potassium chloride 10%, it did not have an open date. During an observation, on 3/26/26 at 11:14 AM, on the 300-hall (front) cart, Resident 2 had an open bottle of Guaifenesin 100 milligrams (mg)/15 milliliter (ml), there was no open date. Resident 9 had an open bottle of Guaifenesin liquid 100mg/5ml, there was no open date observed. […]

• No harm, potential for more than minimal, isolatedF684Mar 19, 2026

  Based on interview and record review the facility failed to ensure medications were administered as ordered for 1 of 3 residents reviewed (Resident B).Findings include:In an interview on 3/18/26 at 10:30 AM, Resident B indicated he did not receive his medications as ordered.Resident B's record was reviewed on 3/18/26 at 12:05 PM. Diagnoses included hypertension and type 2 diabetes mellitus.Resident B's Medication Administration Record (MAR), dated 2/26/26-3/10/26, indicated Resident B had an order for clonidine HCl (antihypertensive) 0.5 mg to be given twice a day orally. […]

• No harm, potential for more than minimal, isolatedF620Nov 17, 2025

  Based on interview and record review the facility failed to perform admission agreements in a timely manner for 3 of 3 residents reviewed. (Resident Q, Resident R, and Resident S).Findings include: 1) Resident Q's record was reviewed on 11/17/25 at 9:26AM. Resident Q was admitted on [DATE].Resident Q's admission agreement paperwork was signed on 10/29/25, 4 days after admission. The admission agreement was dated 10/25/25 and included the following: Resident obligations, Consent for Treatment, Services, Payments for Room Rate, Medicare and Medicaid Programs, Personal Finances, Termination Transfers and Discharges, Bed Hold Policy, Personal Property, Resident Records, Privacy, Non-Discrimination, Dispute Resolution, Limitations of Community, Miscellaneous Provisions and signatures.In an… […]

• No harm, potential for more than minimal, isolatedF628May 19, 2025

  Based on interview and record review, the facility failed to ensure the documentation of required information for hospital transfers was present for 1 of 2 residents reviewed (Resident 24). Findings include: Resident 24's record was reviewed on 5/14/25 at 9:57 AM. Diagnoses included end stage kidney disease, heart failure and emphysema. Resident 24 had a cardiac pacemaker and was dependent on dialysis. Resident 24's Annual Minimum Data Set, (MDS) dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 14 (no cognitive impairment). A progress note, dated 8/24/24 at 7:40 PM, indicated Resident 24 had been transferred to the hospital. The progress note indicated the receiving hospital had been notified. […]

• No harm, potential for more than minimal, isolatedF604May 3, 2023

  Based on observation, interview, and record review the facility failed to be free of physical restraint for 1 of 1 resident reviewed. (Resident 29) Finding include: During an observation, on 4/26/23 at 10:04AM, Resident 29 was in the dining room of the memory care unit. Resident 29 was sitting in a chair with arms. The chair was up against a partial wall and the table was pulled up flush to Resident 29's stomach. There were peers in wheelchairs on each side of Resident 29 during this observation. Resident 29 could not get up, or away from the table. During an observation on 4/28/23 from 10:36AM to 11:05AM, Resident 29 was sitting in the armed chair in dining room. The chair was up against a partial wall and the table was pulled up flush to Resident 29's stomach. […]