New Bethany Skilled Nursing

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep one of three sampled residents (Resident 1) free from falls when Resident 1 fell after Certified Nursing Assistant (CNA) 3 completed a two-person required mechanical lift (device used to safely raise, lower and transfer individuals with limited mobility) transfer without assistance using a stand-up lift (device to assist individuals transfer from a seated position to a standing position), failing to follow the resident's care plan and physician's order requiring a Hoyer lift (overhead full body sling lift) transfer. This failure resulted in Resident 1's fall causing her discomfort and need to be transported to the emergency department (ED) on 11/20/25 for evaluation and had the potential to cause significant injury and harm. During a review of the facility's report dated 11/19/25, the report indicated, . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of practice for two of four sampled residents (Resident 9 and 23 ) when:1. The Nutritional assessment was not completed by the Registered Dietitian (RD) for Resident 9's significant change of condition assessment dated [DATE]. This failure had the potential to put Resident 9 at an increased risk unavoidable significant weight loss. 2. Licensed Vocational Nurse (LVN) 1 did not assess Resident 23's pain prior to administering PRN (means as needed) pain medication (Acetaminophen - is a medication used to treat minor aches and pain and to reduce fever) on 9/3/25. This failure had the potential for Resident 23 not to receive an appropriate pain medication to effectively manage her pain. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional standards for five of eight residents (Residents 1, 8, 20, 21 and 28) when: 1. Residents 1 ,8 , 20, 21 and 28's medications located in the medication cart had the room number of the residents listed and had no label with patient identifiers (information used by healthcare providers to accurately and reliably identify a patient like name and date of birth ). These failures had the potential to result in a medication error (medication being given to the wrong patient).2. The medication room was widely open and unattended by authorized staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food services safety for 29 of 29 sampled residents when:1. A portion of Chicken meat was not fully submerged in water while thawing under running water2. The dishwasher had built up white residue on the surface and black dirt and debris on the top surfaceThese failures placed residents at risk for foodborne (sickness resulting from contaminated food) illness and food contamination.1. During a concurrent observation and interview on 9/2/25 at 9:00 a.m. with [NAME] 1, chicken meat was being thawed under running water, a portion of the meat was not fully submerged under water or in the path of the running water. [NAME] 1 stated the meat should have been fully submerged under water or in the path of the running water. [...]

Inspectors wroteBased on interview and record review the facility failed to implement the quality assurance performance improvement (QAPI- a meeting where staff members come together to talk about ways to improve the quality of care for patients and prevent problems before they happen) plan for 29 of 29 sampled residents when the Registered Dietitian's (RD) QAPI recommendation to be involved in Interdisciplinary Team (IDT- a collaborative meeting where professionals from various disciplines [such as doctors, nurses, therapists, and social workers], come together to discuss and coordinate care for an individual) meetings were not followed:This failure had the potential to have resident weight changes go unmonitored by the RD.During an interview on 9/4/25 at 10:07 a.m. with the RD, the RD stated she has emailed the facility her QAPI report and recommendations for the facility to implement. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in the medication room and for two of two sampled residents (Residents 3 and 15) when 1. Licensed Vocational Nurse (LVN) 1 stored her personal belongings inside of the medication room on the medication counter. 2. Resident 15's oxygen nasal cannula (NC - a plastic tube used to deliver oxygen) was stored in an open package.3. Resident 3's NC was stored in the top drawer of the resident's nightstand with no packaging to protect it from the environment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote the rights of the residents, and treat residents with respect and dignity for two of three sampled residents (Resident 7 and 22) when1. The facility did not use an alternate communication method with non-English speaking resident (Resident 7) such as language assistance, communication card, interpreters or translated materials. This failure violated Resident 7's rights to understand the care provided to her in a language she understood and had the potential to result in Resident 7's needs to go unmet.2. Resident 22 was waiting to be fed by the nursing staff while watching another resident eating lunch meal at the same table on [DATE]. This failure violated Resident 22's right to be treated with respect and dignity in a manner which recognized each resident's individuality. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for two of six sampled residents (Resident 7 and 9) when:1. The facility did not use an alternate communication method with non-English speaking resident (Resident 7) such as language assistance, communication card, interpreters or translated materials. This failure violated Resident 7's rights to understand the care provided to her in a language she understood and had the potential to result in Resident 7's needs to go unmet.2. Resident 9's fall care plan intervention to minimize fall related injuries was not implemented. Resident 9 did not have bilateral floor mats on the sides of the bed. This failure had the potential to place Resident 9 at an increased risk of an avoidable fall and obtaining fall-related injuries. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services which ensured appropriate receipt, reconciliation and identification of controlled drugs (medications with potential for abuse or addiction and are required by federal law to be accounted for by Licensed Nurses) for two of seven sampled residents (Residents 10 and 14) when Licensed Nurses did not verify and ensure completion of the controlled drug record upon receipt from the pharmacy. This failure had the potential for drug diversion (drugs used illegally) of controlled substance medications. During an interview on 9/5/25 at 10:49 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representative in writing of the transfer to the General Acute Care Hospital (GACH) for one of three sampled residents (Resident 33) when Resident 33 was transferred to the GACH on 7/4/2025 and his Responsible Party (RP - a person responsible for another person's healthcare decisions) was not informed of the reason for the transfer. This failure resulted in the lack of written notification for Resident 33's change in condition. During an interview on 9/6/25 at 8:18 a.m. with the License Vocational Nurse/Director of Staff Development (LVN/DSD), the LVN/DSD stated, Resident 33 was transferred to a GACH on 7/4/25. The LVN/DSD stated Resident 33's RP was given verbal notice of Resident 33's transfer to the hospital on 7/4/25. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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)

Inspectors wroteBased 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)

Inspectors wroteBased 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)

Inspectors wroteBased 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)

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]