New Bethany Skilled Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to revise a comprehensive person-centered care plan to reflect assessments and interventions to address a significant change of condition for one of three sampled residents (Resident 9) when Resident 9's care plans were not updated and revised after completion of significant change of condition assessment. 1.Resident 9's nutritional care plan was not revised to reflect Resident's 9's significant change of condition assessment dated [DATE]. 2. Resident 9's activities care plan was not revised to reflect Resident's 9's significant change of condition assessment dated [DATE].These failures had the potential for Resident 9 not to receive the necessary care and services and put Resident 9 at an increased risk of not having her needs met.1.During an observation on 9/2/25 at 9:45 a.m. with Resident 9, in Resident 9's room, Resident 9 was lying in bed, asleep. Resident 9's bedside table contained a full pitcher of water.During a concurrent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure nail care was provided for one of three sampled residents (Resident 9) when Resident 9's fingernails were long and dirty with brownish dirt built up underneath the nails.This failure had potential for Resident 9 in obtaining avoidable skin related injuries (including cuts (laceration), scrapes (abrasion), scratches, etc.) and infection (the invasion and growth of germs in the body).During a concurrent observation and interview on 9/2/25 at 11:00 a.m. with Resident 9, in Resident 9's room, Resident 9 was awake, alert oriented to her name only. Resident 9 stated her name and declined to be interviewed. Resident 9's left hand fingernails are long and dirty with brownish dirt built up underneath the nails mostly on left thumb finger. Resident 9's right hand was tucked underneath the blanket.During a concurrent observation and interview on 9/4/25 2:35 p.m. with Certified Nursing Assistant (CNA) 2, in Resident 9's room, Resident 9's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a hearing device was in placed to maintain resident's hearing abilities for one of three sampled residents (Resident 1) when Resident 1 had not been using a left ear implant hearing device (a surgical device that restores or improves hearing in individuals with severe hearing loss or deafness).This failure had resulted in Resident 1 experiencing a difficulty in hearing during conversation with staff and other residents and having the potential not to effectively communicate his needs with the staff. During an observation on 9/2/25 at 12:00 p.m. with Resident 1, in the dining room, Resident 1 was sitting in a wheelchair in front of the table waiting for his lunch meal. Resident 1 was alert and oriented to his name. Resident 1 was pleasant, clean and well groomed. Resident 1 had difficulty hearing during the conversation. During a concurrent observation and interview on 9/2/25 at 12:05 p.m. with Certified Nursing Assistant (CNA) 3,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received and was provided food that accommodates the resident's preferences or provide a substitute meal of similar nutritive value for two of three residents (Residents 1 and 25) when1. Resident 1 was served and consumed non-fortified substitute/alternative food during lunch on 9/2/25.2. Resident 25 disliked gravy and was provided lunch with gravy, ate 10 percent of the meal, and was not offered a substitute meal at lunch on 9/2/25. This failure had the potential for Residents 1 and 25 not meeting the calories required to maintain the weight and nutritional status and placed Residents 1 and 25 at risk for avoidable significant weight loss. 1.During an observation on 9/2/25 at 12:00 p.m. with Resident 1, in the dining room, Resident 1 was sitting in a wheelchair in front of the table waiting for his lunch meal. Resident 1 was alert and oriented to his name. Resident 1 was pleasant, clean and well groomed. Resident 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that medical records were complete and accurately documented for one of three sampled residents (Resident 4) when Resident 4's Physician Order for Life-Sustaining Treatment (POLST- a document that contains a persons end of life wishes) form was not signed by Resident 4's current responsible party (RP-an individual who has control over healthcare decisions).This failure had the potential to result in Resident 4's healthcare wishes not being followed.During an interview on [DATE] at 11:38 a.m. with Social Services Director/ Medical Records (SSD/MR) the SSD/MR stated the process of the facility was to review and update the POLST form once a year and as needed. The SSD/MR stated Resident 4's spouse was her RP before 5/2025. The SSD/MR stated, Resident 4's spouse's health status changed, and he was no longer able to make healthcare decisions. The SSD/MR stated Resident 4's RP was currently her son. The SSD/MR stated Resident 4's POLST needed to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to identify and monitor safety and accident hazards (are situations or factors with the potential to cause harm or damage in a workplace) when a personal portable electric heater (is a device that converts electric current into heat) was being used in the Infection Preventionist (IP) room. This failure placed the facility at an increased risk of fire.During a concurrent observation and interview on 9/5/25 at 8:40 a.m. with the Social Services Director (SSD), in SSD/IP's room, a personal portable electric heater was located on the floor at the back of the IP's chair. The IP nurse was not in the room. The SSD stated the personal portable heater belonged to the IP nurse. The SSD stated it was hot in the room. The SSD stated the IP nurse had been using her personal portable heater because she was always cold.During an observation and interview on 9/5/25 at 9:17 a.m. with the Maintenance Supervisor (MTNS), the MTNS went to IP's room, and the personal portable electric heater was on with heat coming out. The MTNS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure there was a full-time qualified person responsible for food and nutrition services (FNS) when the Registered Dietitian and Dietary Services Supervisor (DSS) were employed part time and failed to provide the required number of hours for oversight of FNS. This failure resulted in a lack of oversight for food and nutrition services and had the potential to compromise the dietary and nutritional needs of the residents. (Cross reference F812) Findings: During a concurrent observation and interview on 10/7/24 at 10:44 a.m. with Dietary Aide (DA) 1, DA 1 was in the kitchen with a hair restraint on, hair was hanging out of the restraint around her ears, temples, and forehead. DA 1 stated the Dietary Services Supervisor (DSS) was off and because she had a full-time job at a different facility. During a concurrent interview and record review on 10/7/24 at 10:49 a.m. with the Assistant [NAME] (AC), the AC stated the DSS was part time and would normally come to the facility on weekends, in the evenings or early…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food services safety when: 1. The spice storage area contained food products which were not discarded on or before the expiration dates according to facility policies. 2. There was a cart with multiple personal belongings and used items in the kitchen area. 3. Four of four staff did not have their hair properly covered by a hair restraint. These failures placed residents at risk for foodborne illness and contamination. (Cross reference F801) Findings: During an observation on 10/7/24 at 10:44 a.m. with Dietary Aide (DA) 1, DA 1 was in the kitchen and her hair restraint was not covering the hair around her ears, temples, and forehead. During an observation on 10/7/24 at 10:49 a.m. with the Assistant [NAME] (AC), the AC did not have her hair restraint on properly, exposing a large amount of hair above both ears. During a concurrent observation and interview on 10/7/24 at 10:53 a.m. with the AC, a rolling cart was observed in the kitchen, under…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notification of the Bed-hold notice at the time of transfer for one of three sampled residents (Resident 1), when Resident 1 was transferred to the acute care hospital (ACH) on 7/11/24 and the responsible party (RP) was not provided the written Bed-hold notice which specifies the duration of the Bed-hold policy according to federal regulations. This failure placed Resident 1 at risk for his resident rights to be violated. (Cross reference F626) Findings: During a telephone interview on 8/5/24 at 3:13 p.m. with Resident 1 ' s family member (FM) 1, FM 1 stated Resident 1 was transferred from the skilled nursing facility (SNF) to the ACH on 7/11/24. FM 1 stated the ACH had notified the Responsible Party (RP) they were ready to discharge Resident 1 back to the Skilled Nursing Facility (SNF) on 7/18/24 and the SNF had refused to readmit the resident. During an interview on 8/6/24 at 10:20 a.m. with the Administrator (ADM) and Director of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who were hospitalized were permitted to return to the facility for one of three sampled residents (Resident 1) when the facility refused to take Resident 1 back after Resident 1 was medically cleared (when a patient no longer needs to receive inpatient care) to return to the facility from the acute care hospital (ACH). This failure placed Resident 1 at risk for psychosocial harm by not allowing the resident to return to the skilled nursing facility (SNF) near his home and caused him to be transferred to a SNF in a different city. This caused a hardship for Resident 1 ' s spouse when she had to decrease the frequency of her visits to the resident. (Cross reference F625) Findings: During a telephone interview on [DATE] at 3:13 p.m. with Resident 1 ' s family member (FM) 1, FM 1 stated Resident 1 was transferred from the skilled nursing facility (SNF) to the ACH on [DATE]. FM 1 stated the ACH had notified the responsible…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure two of 12 sampled residents (Resident 128 and 19) were treated with dignity and respect when: 1. Resident 19 was assisted with lunch by Certified Nursing Assistant (CNA) 1, CNA 1 did not engage in conversation and did not inform the resident when she was providing beverages, spoons with food or wiping her face. This failure resulted in Resident 19 not being provided a respectful and dignified dining experience which could further enhance resident's quality of life. 2. Resident 128's urinary catheter (a flexible tube inserted through a narrow body opening into the bladder and used for draining urine) bag was left uncovered. Findings: 1. During an observation on 6/19/24 at 12:20 p.m. in the facilities dining room, CNA 1 was seated next to Resident 19 assisting her with her lunch. Resident 19 was nonverbal; her eyes were closed, fists clenched, and she was unable to feed herself. Resident 19 had a white cloth fastened around her neck covering the front of her chest area. CNA 1 was placing spoons of food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide services which met professional standards of practice for 17 of 25 sampled residents (Residents 1, 2, 3, 4, 6, 10, 11, 12, 13, 14, 15, 17, 18, 19, 21, 127, and 128) when: 1. LVN 1 failed to explain the medication name and indication to Resident 1, 13, 18, 21, 127, and 128 during medication administration. This failure had the potential to place Residents 1, 13, 18, 21, 127, and 128 at risk of receiving the wrong medication and experience unnecessary side effects. 2.The facility failed to have a Licensed Nurse confirm the lunch meal tray matched residents' dietary orders for Residents 2, 3, 4, 6, 10, 11,12, 13, 14, 15, 17, 18, 19, and 21. This failure had the potential to place Residents 2, 3, 4, 6, 10, 11,12, 13, 14, 15, 17, 18, 19, and 21, at risk of receiving the wrong meal, choking, allergic reactions and weight loss. Findings: 1. During a medication pass observation on 6/18/24, at 11:01 a.m., inside Resident 127's room, LVN 1 administered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program to prevent the development and transmission of diseases for seven of 18 sampled resident (Resident 128, 8, 1, 9 177, 16, and 19) when: 1. Resident 177 was on contact precautions and isolations gowns were not stocked and available outside the room for staff to use. 2. Certified Nurse Assistant (CNA) 1 did not use an alcohol-based hand rub (ABHR-an alcohol containing liquid, gel or foam rubbed on hands that kill microorganisms) when passing out breakfast trays for five of seven residents (Resident 128, 8, 1, 9, 177). 3. CNA 1 failed to use an ABHR prior to and after feeding two of two residents (Resident 16, 19). This failure had the potential to result in the transmission of infection between residents. Findings 1. During an observation on 6/18/24 at 10:51 a.m. outside Resident 177's room, there was an orange sign on the left side of the door that indicated Resident 177 was on contact isolation (a patient with a contagious disease that can spread by touch). Below…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plan for ten of ten sampled residents (1, 4, 5, 7, 10, 13, 14, 15, 16, and 222) when: 1. Resident 7 had four bed rails raised. Prior to the use of the four bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the four bed rails. 2. Resident 16 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 3. Resident 15 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. After prompting from the surveyor, the consent, physician order and care plan were implemented on 9/22/22. 4. Resident 13 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure ten of ten Residents (Residents 1, 4, 5, 7, 10, 13, 14, 15, 16, and 222) were assessed for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard (raised) or lowered position) prior to installation and had no consent (form signed by resident or family explaining the risks of side rail use), physician order, indication for use, and care plans prior to the use of side rails when: 1. Resident 7 had four bed rails raised. Prior to the use of the four bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the four bed rails. 2. Resident 16 had two upper bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food was stored and/or prepared in accordance with professional standards for food services safety when: 1. Food products stored in the dry storage area and refrigerator contained food items that were not labeled and dated and discarded on or before the expiration dates. 2. Shelled eggs prepared for residents were not pasteurized eggs. 3. Kitchen staff did not follow the facility's policy for Cool Down. These failures placed residents at risk for foodborne illness and food contamination. Findings: 1. During a concurrent observation and interview on 9/20/22, at 9:01 a.m., with the Dietary Supervisor (DS), in a refrigerator in the kitchen, there were two diet cakes in circular pans with a label adhered to the plastic covering on each cake, and there were no dates written on the label. The DS stated, I made those cakes last night, I put the labels on the cakes but forgot to write down the date. During an observation on 9/20/22, at 9:07 a.m., in the kitchen, there were five clear bins filled with assorted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 20) was free from physical restraints when Resident 20 had a self-releasing seat belt with alarm and the initial physical restraint evaluation had not been performed to determine the need for the seat belt. This failure resulted in Resident 20 to be unnecessarily restrained and kept her from getting up or moving freely due to the self-releasing seat belt. Findings: During an observation on 9/20/22, at 11:40 a.m., in front of room [ROOM NUMBER], Resident 20 was sitting in her wheelchair with a belt across her lap. During a review of Resident 20's Face Sheet, undated, the Face Sheet indicated, Resident 20 was admitted to the facility on [DATE] and had a primary diagnosis of osteoarthritis (occurs when the cartilage that cushions the ends of bones in joints gradually deteriorate), osteoporosis (a disease in which bones become fragile and more likely to break), and difficulty walking. During a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Licensed Nurses have the competencies necessary to meet the needs of the residents for ten of ten sampled residents (Residents 1, 4, 5, 7, 10, 13, 14, 15, 16, and 222) and Licensed Vocational Nurse (LVN) 2 and Director of Staff Development DSD/IP did not have training and competencies on the proper use of bed rails when: 1. Resident 7 had four bed rails raised. Prior to the use of the four bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the four bed rails. 2. Resident 16 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; obtain consent, physician order and care plan prior to the use of the two bed rails. 3. Resident 15 had two bed rails raised. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment. 4. Resident 13 had two bed rails raised. Prior to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the Dietary Services Supervisor (DS) possessed the appropriate competencies and skills set to carry out the functions of the food and nutrition services department in accordance with the DS job description when: 1. The DS did not provide the necessary oversight of food safety, sanitation, and storage in the kitchen: 1a. Dietary staff were not implementing or accurately documenting safe food cool down process. 1b. Dietary staff did not label food and did not dispose expired food. 1c. The DS did not have the required certification or education to meet the needs of the DS position. These failures had the potential to place residents who consumed meals prepared from the kitchen to be at risk for foodborne illnesses related to growth of microorganisms (bacteria or fungus that cause nausea, vomiting, and diarrhea), weight loss, and malnutrition. (cross reference F812) Findings: 1a. During an interview on 9/21/22, at 12:09 p.m., with [NAME] 1, [NAME] 1 stated she did not prepare food the day before to cut…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.