Bethany Center For Rehabilitation And Healing LLC

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 4 of 19 staff members (Certified Nursing Assistant (CNA) F, G, H and Activity Assistant E) failed to perform hand hygiene and handled food with barehand during dining observations, and when 1 of 2 staff (Dietary [NAME] I) failed to perform proper hand hygiene when preparing meal trays. The facility had a census of 166 with 166 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility policy titled Handwashing/Hand Hygiene, dated 10/2023, revealed .All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors .Perform hand hygiene before applying non-sterile gloves. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. When removing gloves .turning the glove inside out .Perform hand hygiene . Review of the undated facility policy titled, Food Sanitation, revealed .All…

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 policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to develop an Advance Directive for 4 of 33 sampled residents (Resident #21, #71, #77 and #108) reviewed for Advance Directives. The findings include: 1. Review of the facility policy titled Advance Directives, revised on 9/2022, revealed .The resident has the right to formulate an advance directive .Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive . 2. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses including of Alzheimer's Disease, Anxiety, Depression, and Diverticulosis.…

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 policy review, Certified Nursing Assistant (CNA) training record review, and interview, the facility failed to ensure 23 of 23 CNAs (CNA G, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, and EE) employed for a full year received at least 12 hours of in-service training. The findings include: 1. Review of the facility's policy titled In-Service Training, Nurse Aide, dated august 2022, revealed .all Personnel are required to participate in regular in-service education .Annual in-service: Ensure the continuing competence of nurse aides; are no less than 12 hours per year . 2. Review of the Inservice Training Hours revealed: a. CNA G had a hire date of 3/30/2024 and had only competed 8.50 in-service hours from 4/3/2024 -present. b. CNA J had a hire date of 9/13/2006 and had only competed 4.0 in-service hours from 9/18/2024 -present. c. CNA K had a hire date of 11/9/2023 and had only competed 2.0 in-service hours from 11/20/2024 -present. d. CNA L had a hire date of 1/31/2023 and had only competed 10.50 in-service hours from 2/5/2024 -present. e. CNA M had 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.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 4 staff members (Registered Nurse (RN) II) left the medication unattended and out of sight at the bedside in Resident #10's room. The findings include: 1. Review of the facility's policy titled Medication Labeling and Storage, dated 5/19/2023, revealed .trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others . 2. Observation on 4/2/2025 at 3:40 PM, revealed Register Nurse (RN) II left the medication on the over bed table in Resident #10's room. RN II went into the bathroom with the door almost closed completely, with a small crack toward the hall, to wash her hands and left the medication out of sight and unattended on the over bed table by B bed. During an interview with surveyors present, on 4/3/2025 at 11:23 AM, the Director of Nursing (DON) was asked should medications be left unattended and out of sight. The DON stated, Did you ask the nurse .was it A bed or B bed .Did she not…

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 Quarterly Payroll Based Journal (PBJ), staffing time sheets, and interview the facility failed to submit accurate staffing data for Quarter 2, Quarter 3, and Quarter 4/2024. The findings included: 1. Review of the PBJ Staffing Data Report for Quarter 2 2024 (January 1-March 31) revealed excessively low weekend staffing. Review of the PBJ Staffing Data Report for Quarter 3 2024 (April 1-June 30) revealed one star staff rating and excessively low weekend staffing. Review of the PBJ Staffing Data Report for Quarter 4 2024 (July 1-September 30) revealed excessively low weekend staffing. 2. Review of the Direct Care Staffing which included the facility census, direct care staff hours, and PPD (Per Patient Day-total hours of Registered Nurse Hours, Licensed Practical Nurse Hours, and Certified Nursing Assistant hours divided by the resident census = hours of care provided to each resident in a facility) provided by the Administrator via email on 4/11/2025 revealed the following: Saturday 3/16/2024 Total PPD 2.83 Saturday 4/27/2024 Total PPD 2.96 Saturday 5/25/2024 Total PPD 2.74…

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 policy review, medical record review, observation, and interviews, the facility failed to ensure infection control practices to prevent the spread of infection were used when 1 of 5 (Registered Nurse (RN II) nurses failed to perform hand hygiene during medication administration and Certified Nursing Assistant (CNA) LL was not following Enhance Barrier Precautions (EBP)s while providing care for Resident #311. The findings include: 1. Review of the facility policy titled Instillation Eye Drops, dated 1/2014, revealed Should both eyes require instillation, wash and dry your hands thoroughly before treating each eye. Review of the facility policy titled, Enhanced Barrier Precautions, dated 4/2024 revealed, .Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents .EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.…

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 interviews, record review, and facility document and policy review, it was determined the facility failed to ensure a comprehensive care plan was updated to address how a resident was to be transferred for 1 (Resident #6) of 11 residents whose care plans were reviewed. Findings included: Review of a facility policy titled, Comprehensive Person-Centered Care Plans, dated 03/08/2023, revealed, 11. Assessment of residents are ongoing and care plans are revised as information about the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS [Minimum Data Set] assessment. A review of Resident #6's admission Record revealed the facility admitted the resident on 11/20/2020 with diagnoses that included end…

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 facility policy review, medical record review, observation, and interview, the facility failed to provide food and beverages at a palatable and appetizing temperature for 1 tray delivery cart, containing 22 resident meal trays, of 3 tray delivery carts delivered to the 1st floor. The findings include: Review of the undated facility policy, Food Temperatures, revealed .Foods should be transported as quickly as possible to maintain temperatures for delivery and service . Medical record review revealed Resident #54 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Psychosis, Disorder of Carbohydrate Metabolism, Dementia with Behavior Disturbance and Hypertension. Medical record review of Resident #54's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9 indicating the resident was moderately cognitively impaired. Interview with Resident #54's family member on 10/21/19 at 1:52 PM in Resident…

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 review of facility policy, observation, and interview, the facility failed to ensure food was served under sanitary conditions when a male dietary employee with facial hair was observed working on the tray line without wearing a beard net on 1 of 3 observations. Findings include: Review of facility policy, General Sanitation of Kitchen dated 2013 revealed .beard nets are required when facial hair is visible . Observation of the noon meal on 7/9/18 at 11:35 AM in the dietary department revealed one male dietary employee working on the residents tray line with visible facial hair not wearing a beard net. Interview with the Dietary Manager on 7/9/18 at 11:36 AM in the dietary department confirmed the male employee failed to wear a beard net to cover facial hair while working on the tray line.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, medical record review, observation and interview, the facility failed to change a soiled dressing Percutaneous Inserted Central Catheter (PICC) (a line that goes into your arm and runs all the way to a large vein near the heart for long term intravenous therapy) as ordered for 1 (#1) of 7 residents reviewed. Findings include: Review of facility policy IV Tubing and Dressing Changes dated 10/1/07 revealed .PICC line dressings will be changed weekly . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Severe Sepsis without Shock, Pneumonia, and Methicillin Resistant Staphylococcus Aureus (MRSA). Medical record review of the Physician Orders dated 7/10/18 revealed .change PICC line dressing 24-48 hours after insertion of line if dressing is soiled and then every 7 days . Observation on 7/10/18 at 9:50 AM in Resident #1's room revealed an old soiled transparent dressing, covering the PICC line of the upper left arm with 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.