Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pruitthealth - Bethany during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a need for two-person assistance fell from a bed during unassisted ADL care, resulting in a fatal head injury. The CNA provided care alone, contrary to the resident's documented needs, and raised the bed height, increasing fall risk. Staff interviews revealed a lack of adherence to care protocols, contributing to the incident.
A resident in a long-term care facility suffered a serious head injury after falling from bed due to inadequate assistance during ADL care. The care plan inaccurately specified one to two-person assistance, despite the resident's documented need for two-person help. Staff interviews revealed inconsistencies in understanding the resident's care needs, contributing to the incident.
A resident, dependent on staff for mobility, fell from bed during ADL care, resulting in death. The CNA, who attempted care alone, raised the bed to waist height, leading to the resident rolling off and sustaining severe head injuries. Despite emergency intervention, the resident died shortly after.
A resident fell from the bed and died at the hospital due to neglect during ADL care. The facility failed to ensure the resident was free from neglect and did not develop a comprehensive care plan specifying the need for two-person assistance. The Administrator and DHS were found to have failed in their oversight responsibilities.
Neglect During ADL Care Leads to Resident's Death
Penalty
Summary
The facility failed to protect a resident from neglect during Activities of Daily Living (ADL) care, resulting in a severe injury and subsequent death. The incident involved a Certified Nursing Assistant (CNA) providing unassisted care to a resident with severe cognitive impairment and a requirement for two-person assistance. During the care, the resident rolled off the bed, sustaining a 14 cm head laceration with the scalp pulled away, exposing the skull. The resident was transported to the hospital but expired shortly after the fall. The facility's policy on abuse and neglect clearly defines neglect as the failure to provide necessary goods and services to avoid harm. Despite this, the CNA proceeded to provide care alone, contrary to the resident's documented need for two-person assistance. Interviews with staff revealed that the CNA had been changing the resident without assistance, despite the resident's inability to assist in her care and the absence of bed rails, which were previously used to aid in turning the resident. Staff interviews further highlighted a lack of awareness and adherence to the resident's care requirements. The CNA believed she could manage the resident's care alone based on their interaction, while other staff members confirmed the resident's need for maximum assistance. The incident was compounded by the CNA's decision to raise the bed to her waist height, increasing the risk of injury from a fall. The facility's failure to ensure adherence to care protocols and proper staffing during ADL care directly contributed to the resident's injury and death.
Failure to Implement Accurate Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to develop an accurate person-centered comprehensive care plan for a resident, which specified the need for two-person assistance with Activities of Daily Living (ADL) care. The care plan for the resident, revised on 7/1/2024, indicated that the resident required maximum to total assistance with ADL care, including bed mobility, transfers, locomotion, and toileting, with approaches for one to two-person assistance. However, the Minimum Data Set (MDS) for the resident documented that the resident was dependent and required the assistance of two or more helpers for certain activities. This discrepancy in the care plan led to an incident where the resident fell from the bed while being cared for by a single CNA, resulting in a serious head injury. Interviews with facility staff revealed inconsistencies in the understanding and implementation of the resident's care needs. The CNA involved in the incident believed she could manage the resident's ADLs alone based on their interaction that day, while other staff members, including a hospice CNA, confirmed that the resident typically required two-person assistance. The facility's policy required care plans to be comprehensive and person-centered, yet the care plan did not clearly specify the consistent need for two-person assistance, leading to a failure in providing adequate care and supervision for the resident.
Inadequate Assistance Leads to Resident's Fatal Fall
Penalty
Summary
The facility failed to provide adequate assistance for bed mobility, resulting in a resident's fall and subsequent death. The resident, who was dependent on staff for self-care and mobility, fell from the bed during Activities of Daily Living (ADL) care. The Minimum Data Set (MDS) indicated that the resident required the assistance of two or more helpers for mobility. However, on the day of the incident, a Certified Nursing Assistant (CNA) attempted to provide care alone, believing the resident could roll over independently. During the care, the resident rolled out of bed, resulting in a severe head injury and other wounds. The incident occurred when the CNA raised the bed to her waist height to change the resident, who then rolled over unexpectedly, causing the feeding pump to fall on the bed. The resident fell to the floor, sustaining a large laceration to the head, exposing the skull, and other injuries. Despite emergency medical intervention, the resident died shortly after the fall. Interviews with staff revealed that the CNA had previously cared for the resident without assistance, but on this occasion, the lack of additional help led to the tragic outcome.
Neglect During ADL Care Leads to Resident's Death
Penalty
Summary
The facility administration failed to ensure that a resident, identified as R1, was free from neglect during Activities of Daily Living (ADL) care. This neglect resulted in R1 falling from the bed and subsequently expiring at the hospital 50 minutes post-fall. The incident was determined to have occurred on 6/30/2024, and the facility's noncompliance with participation requirements was found to have the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Health Services (DHS) were found to have failed in their responsibilities to protect residents and effectively oversee the facility's operations as outlined in their job descriptions. The facility also failed to develop a comprehensive person-centered care plan for R1, which should have specified the need for two-person assistance during ADL care. This oversight contributed to the fall that led to R1's death. Interviews revealed that the Administrator was not present at the time of the incident but was informed by the weekend supervisor. The Certified Nursing Assistant (CNA) involved was sent home and suspended pending investigation. The DHS confirmed that the CNA was suspended and that R1 was capable of assisting with turning by holding onto the mattress.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 20 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Millen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine View Nursing And Rehab Center | 17.4 mi | ★★★★★ | 11 | 0 |
| Twin City Trails Of Journey Llc | 19.4 mi | ★★★★★ | 9 | 0 |
| Brentwood Health Center By Harborview | 20.1 mi | ★★★★★ | 0 | 0 |
| Westwood Healthcare And Rehabilitation | 25 mi | ★★★★★ | 0 | 0 |
| Brown's Health And Rehabilitation | 26.2 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pruitthealth - Bethany.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.