Bethany Woods Nursing and Rehabilitation Center

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to ensure that residents were treated in a dignified and respectful manner. This was evidenced by staff arguing with a resident and using profanity in the resident's presence for 1 of 4 residents reviewed for dignity (Resident #7).

Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to ensure a resident's call light system was placed within reach and accessible for 1 of 8 residents reviewed for accommodation of needs (Resident #7).

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to provide personal privacy during incontinence care when Nurse Aide (NA) #1 captured a picture of Resident #42 with her cellphone while in the room during care. Resident #42 was partially clothed and uncovered in the photo. This deficient practice affected 1 of 1 resident reviewed for privacy (Resident # 42).

Inspectors wroteBased on observations, record reviews, and resident, staff, and Medical Director interviews, the facility failed to ensure oxygen was delivered at the prescribed rate. This deficient practice occurred for 1 of 4 residents reviewed for respiratory care (Resident #11).

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 27 opportunities, resulting in a medication error rate of 7.41% for 2 of 3 residents observed for medication administration (Resident #129 and Resident #110).

Inspectors wroteBased on record review and staff interviews, the facility failed to post accurate daily staffing information as compared to the daily staffing schedules for licensed and unlicensed nursing staff for 19 out of 30 days (3/1/26, 3/2/26, 3/3/26, 3/4/26, 3/5/26, 3/6/26, 3/7/26, 3/8/26, 3/12/26, 3/13/26, 3/14/26, 3/17/26, 3/19/26, 3/20/26, 3/21/26, 3/24/26, 3/26/26, 3/27/26, and 3/28/26).

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure resident rooms were maintained in good repair for 7 of 19 resident rooms reviewed for clean, comfortable and homelike environment (Residents #3, # 8, #31, #37, #63, #65, and #72). The facility also failed to ensure the Packaged Terminal Air Conditioner (PTAC) unit (Resident #3) was kept clean for 1 of 19 resident rooms observed. This deficient practice affected 3 of 8 facility hallways.

Inspectors wroteBased 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).

Inspectors wroteBased 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). This deficient practice affected 2 of 8 residents whose medications were reviewed (Residents #23 and #4).

Inspectors wroteBased on record reviews, and Nurse Practitioner (NP), Medical Director, family member, and staff interviews, the facility failed to prevent medication errors when Nurse #1 administered medications to Resident #23 prescribed for Resident #240 which included fish oil (used to promote health by reducing triglycerides) and famotidine (decreases stomach acid and used to treat heart burn and gastroesophageal reflux disease). The facility also failed to prevent medication errors when medications were not administered as ordered by the physician (Resident #55). This deficient practice affected 2 of 8 residents whose medications were reviewed (Residents #23 and #55).

Inspectors wroteBased 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).

Inspectors wroteBased on record reviews and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification and complaint survey conducted on 2/3/2022. This was for 5 deficiencies in the areas of resident rights, safe/clean/comfortable homelike environment, accuracy of assessments, care plans, and services to meet professional standards, previously cited on 2/3/2022 and recited on the current recertification and complaint survey of 8/31/23. The duplicate citations during two federal surveys of record show a pattern of the facility's inability to sustain an effective QAPI program.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to avoid the use of the term feeder when referring to a resident who required assistance with meals for 1 of 1 dining observations (Resident # 87). The reasonable person concept was applied as individuals have the expectation of being treated with dignity and not be referred to as feeder.

Inspectors wroteBased on observation, record review, and staff and resident interviews, the facility failed to assess Residebt #22 for self administration of medication for 1 of 1 resident observed to self-administer medication.

Inspectors wroteBased on record review and interviews with staff, the facility failed to request a level II Preadmission Screening and Resident Review (PASRR) for a resident (Resident #81) newly diagnosed mental illness for 1of 1 residents reviewed for PASRR.

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to develop a comprehensive care plan in the areas of personal and incontinence care refusal (Resident #32) and nutrition and weight loss (Resident #50) for 2 of 22 residents reviewed for care plan.

Inspectors wroteBased on observations, resident and staff interviews and record review, the facility failed to provide assistance with eating to maintain a resident's ability to feed himself for 1 of 1 residents (Resident #87) reviewed for activities of daily living (ADL).

Inspectors wroteBased on observations and staff interviews, the facility failed to have a Packaged Terminal Air Conditioner (PTAC) unit in good repair (room [ROOM NUMBER]). This was for 1 of 6 rooms reviewed for comfortable, clean, and homelike environment.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of medications (Resident #13 and Resident #42 ) for 2 of 22 residents reviewed.

Inspectors wroteBased on record reviews, observation, and staff interviews, the facility failed to clarify a consultation note and discontinue an order to flush an abscess drain (Resident #25). This was for 1 of 1 resident reviewed for well-being.