Bethel Nursing Home Company Inc

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that an injury of unknown origin was reported to the State Agency immediately, but not later than two hours for one of two residents (Resident #6) reviewed for injury of unknown origin. Specifically, on 08-30-2025 Resident #6 was transferred to the hospital after they complained of right hip pain with right leg swelling and abduction of the right knee. On 08-31-2025 at 2:26 AM the facility was made aware that Resident #6 was diagnosed with a right hip fracture. The State Agency was not notified until 09-01-2025 at 1:19 PM.

Inspectors wroteBased on record review and interview the facility failed to ensure that a thorough and/or accurate investigation was conducted for one of one resident (Resident #51) reviewed for abuse. Specifically, the Investigative Summary statement from Registered Nurse Supervisor #11 documented the wrong incident date and incorrect initials for Certified Nurse Aide #4 after Resident #51 called 911 on 05/01/2026 and accused staff of abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and/or that each resident receives adequate supervision to prevent accidents for one of two residents (Resident #1) reviewed for accidents. Specifically, the comprehensive Care Plan did not include interventions to address supervision for Resident #1 who was assessed as at risk for elopement, was able to remove their wander guard and exit the building unsupervised on the morning of 06/22/2025. Additionally, there was no consistent documented evidence that every 15-minute monitoring x 48 hours was implemented as per the comprehensive Care Plan after Resident #1eloped on 06/22/2025.

Inspectors wroteBased on staff interview and review of facility documents, it was determined that, the facility did not ensure each certified nurse aide received twelve hours in-service education per year based on their individual performance review. Specifically, (1) 4 out of 5 certified nurse aides did not have their mandatory annual 12 hour in services and (2) 5 out of 5 certified nurse aides (#2,6, 7, 8, 9) did not receive performance evaluations. Finding Include: Review of facility training records revealed: Certified Nurse Aide # 2 was hired on 2/28/2011 and received 10.25 hours of in-services in the last 12 months and had no documented evidence of an annual performance review. Certified Nurse Aide # 6 was hired on 12/17/2007and received 0 hours of in-services in the last 12 months and had no documented evidence of an annual performance review. [...]

Inspectors wroteBased on observations and interviews conducted during the recertification survey from 3/18/25 to 3/21/25, the facility did not store, distribute and serve food in accordance with professional standards for food service safety and did not maintain dishwasher heat for sanitation. Specifically, 1) expired foods were stored in dry pantry, walk in refrigerator and freezer; 2) unsealed, unlabeled and undated food were stored in dry pantry and walk in refrigerator; 3) the dishwasher wash and rinse did not maintain proper temperature standards; and 4) three (3) staff were observed not performing proper hand hygiene while serving the lunch meal.

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey from 3/18/25 to 3/21/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the facility did not provide documentation of screening, administration, or declination and education provided for 5 of 10 staff (Certified Nurse Aide #1 and #4, Licensed Practical Nurse #1, Registered Nurse Supervisor #1, Dietary Aide #3) reviewed for influenza and 10 of 10 staff (Certified Nurse Aide #1, #2, #4, Licensed Practical Nurse #1, Registered Nurse Supervisor #1, Dietary Aide #3, Director of Environmental Services, Director of Housekeeping, Physical Therapist #1 and Housekeeping Aide #1) reviewed for pneumococcal vaccination.

Inspectors wroteBased on observation, record review and interview conducted during a Recertification survey from 3/18/25 to 3/21/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the facility did not provide documentation of screening, administration or declination and education provided for 10 of 10 staff (Certified Nurse Aide #1, #2, #4, Licensed Practical Nurse #1, Registered Nurse Supervisor #1, Dietary Aide #3, Director of Environmental Services, Director of Housekeeping, Physical Therapist #1 and Housekeeping Aide #1), reviewed for COVID vaccination.

Inspectors wroteBased on observation, interview, and record review, during the recertification survey from 3/18/25 to 3/21/25 the facility did not ensured that the call bell system was accessible for 1 (Resident #16) of 35 residents reviewed for Environment. Specifically, the facility did not ensure that Resident's #16 call bell was within reach.

Inspectors wroteBased on record reviews and interviews during a recertification survey from 3/18/25-3/21/25 the facility did not ensure a resident's right to be free from misappropriation of resident property for 1 out of 1 resident (Resident #12) reviewed for personal property. Specifically, Resident #12 was missing shirts which was reported to facility staff and the facility did not complete a timely and thorough investigation of the missing property.

Inspectors wroteBased on record review and interview during a recertification survey from 3/18/25 to 3/21/25, the facility did not ensure resident received treatment and care consistent with professional standards of practice for 1 of 2 Residents (Resident #13) reviewed for skin conditions. Specifically, Licensed Practical Nurse #1 failed to report a change in Resident #13's skin condition.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 3/18/25 to 3/21/25, the facility did not ensure residents were provided supervision to prevent accidents for 1 (Resident #33) of 2 residents reviewed for accidents. Specifically, Resident #33 was at risk for aspiration and was not provided supervision or assistance by facility staff during meals. The resident was observed being fed by an unqualified companion aide.

Inspectors wroteBased on observation, record review and interviews during a recertification survey conducted from 3/18/25 to 3/21/25, the facility did not ensure the provision of nutrition and hydration care and services for 1 of 3 residents reviewed for Nutrition (Resident #5). Specifically, Resident #5 had a 6.3% weight loss over 1 month, and meal intake was not consistently monitored, and the resident was not encouraged with meal and fluid intake as planned.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey from 03/18/25 to 03/21/25, the facility did not ensure a medication error rate of no more than 5%, during a medication administration observation, when 3 of 35 opportunities (8.57%) resulted in error for 1 of 3 residents (Resident #19). Specifically, Resident #19 1) was administered a crushed form of Carbodopa50mg-Levodopa 200mg-entacapone, a crushed form of Acidophilus Probiotic 35 million cell tablet, and 2) an inaccurate dose of Metamucil powder.

Inspectors wroteBased on observation, record review, and interview during the recertification survey the facility did not maintain drugs and biologicals, labeled in accordance with currently accepted professional standards, and include the appropriate accessory and cautionary standards, and expiration dates for 1 of 1 medication storage room (located on the second floor) reviewed. Specifically, the medication storage room (located on second floor) had expired drugs and biologicals that were available and ready for use.

Inspectors wroteBased on record review and interview conducted during an abbreviated survey (NY00310549, NY00313330) the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for 2 resident's (Resident #1 and Resident#2) of 3 residents reviewed for accidents. Specifically, (1) Resident #1 was left in the room unsupervised without prothesis (for right leg) and attempted to self-toilet and fell; (2) Resident #2 fell out of the bed and sustained a hematoma on the left side of the head. The facility did not ensure that the mats that were supposed to be on both side of Resident #2's bed was in place in accordance with the care plan.

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey from 7/31/23 to 8/6/23, the facility did not ensure that resident's had the right to be free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 1 resident's reviewed for restraints (Resident #24). Specifically, Resident #24 was physically restrained in bed with pillows tucked under their sheets, and wedge cushions between the mattress and bed frame, with no documentation of medical symptoms warranting the use of restraints. In addition, the restraints were applied without an assessment and without a physician's order.

Inspectors wroteBased on interview and record review conducted during the recertification survey from 7/31/23 through 8/8/23 and abbreviated surveys (NY00318447, #NY00314225, and #NY00320324), it was determined that for 3 of 3 residents (#13, #15, and #136) reviewed for hospitalizations, the facility did not ensure that the Office of the Ombudsman was notified when the residents were transferred to the hospital. Specifically, Residents #13, #15, and #136 were transferred to the hospital and the facility could not provide evidence that the Ombudsman was notified of their transfers out of the facility.

Inspectors wroteBased on interview and record review conducted during the recertification survey from 7/31/23 through 8/8/23 and an abbreviated survey (#NY00318447, #NY00314225, and #NY00320324), it was determined that for 3 of 3 residents (#13, #15, and #136) reviewed for hospitalizations, the facility did not ensure that the resident or the resident's representative were notified in writing of the facility's Bed Hold Policy. Specifically, Residents #13, #15, and #136 were transferred to the hospital and the facility could not provide evidence that a written notice of the facility's Bed Hold Policy was provided to the residents or the resident's representatives.

Inspectors wroteBased on record review and interview during the recertification survey from [DATE] to [DATE] and an abbreviated survey (#NY00320324), the facility did not ensure that the environment was free of accident hazards, and that each resident received adequate supervision and assistance to prevent accidents for 3 (Resident #3, #30, and #136) of 3 residents reviewed for accidents. Specifically, 1. Resident #3, with impaired cognition and at risk for elopement successfully made it off the unit and to the facility lobby unsupervised on two occasions and 2. Resident #136 and Resident #3 were cut out of a Hoyer Lift after the battery had died and the machine stopped working.

Inspectors wroteBased on observations, interviews, and record reviews conducted during recertification survey from 7/31/23 to 8/8/23, the facility did not ensure services were provided to maintain acceptable parameters of nutritional status for 1 of 1 residents reviewed for nutrition (Resident #17). Specifically, the facility did not ensure Resident #17 was consistently offered assistance and supervision during meals, resulting in missed meals on 2 observed occasions.

Inspectors wroteBased on observation and interview conducted during the recertification survey from 8/1/23 through 8/8/23, the facility did not ensure that medications were discarded to prevent their use beyond the expiration dates for 1/1 medication rooms inspected (2nd floor medication room). Specifically, multiple medications were discovered in the 2nd floor medication room that were expired.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey from 7/31/23 to 8/8/23, the facility did not ensure that infection control practices were maintained. Specifically, A physician (MD) #2 exited the room of a resident on contact precautions (Resident # 679) without performing hand hygiene.

Inspectors wroteBased on interview and record review conducted during a recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. Specifically, the facility did not ensure a person-centered care plan was developed for 2 of 2 residents (#3, #8) reviewed for Dementia Care.

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey, the facility did not ensure that proper hand hygiene was performed during wound care treatment for 1 out of 2 residents (#23) reviewed for pressure ulcers.