Above 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 Bethany Pointe Health Campus during CMS and state inspections, most recent first.
Surveyors found that the facility failed to follow physician-ordered pureed diets for two residents with significant medical conditions, including dementia, dysphagia, and GI diagnoses. Both residents had active orders and care plans for fortified foods with pureed texture due to nutritional risk, yet each was served a whole, non-pureed brownie on a meal tray. Staff, including a CNA and a QMA, encouraged or facilitated the residents’ consumption of the brownies, and the QMA later acknowledged not knowing whether the brownie met pureed diet requirements. The Dietary Manager confirmed that whole brownies are not pureed and that pureed foods must be blended to a paste consistency, while facility leadership indicated that the policy on maintaining current orders in the electronic record also applies to dietary orders.
A resident with COPD and dementia received a nebulizer treatment without staff present, despite lacking a physician order or documented care plan authorization to self-administer medications. The resident was observed in bed holding the nebulizer mask while the machine ran unattended until another staff member entered and turned it off, and the assigned nurse was on break. An RN acknowledged the resident was not able to self-administer but routinely allowed her to complete nebulizer treatments alone due to other medication priorities. Although a self-administration assessment later indicated the resident could self-administer ipratropium-albuterol, this was not yet incorporated into the clinical record, and facility policy required staff to remain with residents during nebulizer treatments unless formally authorized for self-administration.
A resident with Parkinson’s disease, dementia, and chronic incontinence, who required extensive assistance with toileting and personal hygiene, received perineal care from a QMA who did not change gloves or perform hand hygiene after cleaning the perineal area and disposing of a soiled brief, then proceeded to assist with dressing, transfer, and handling of oxygen tubing and nasal cannula. During the same care episode, a CNA placed a soiled bath blanket on the carpeted floor while making the bed, contrary to the facility’s linen-handling policy. The CNA later stated she would not normally place soiled linens on the floor, and the QMA acknowledged forgetting to change gloves after perineal care, while the Executive Director reported there was no policy specifically addressing glove changes after perineal care.
A resident with dementia and a history of exit-seeking behaviors was able to leave a secured unit unsupervised after a visitor entered the code and held the door open, despite the resident's care plan and prior use of a wander guard. The resident was missing for nearly an hour, crossing a highway and traveling almost a mile before being found and returned by a staff member. Staff did not immediately notice the resident's absence, and the facility's elopement prevention policy was not effectively followed.
Two residents who were discharged to the hospital did not receive required bed hold policy notifications, as documentation was either missing or incomplete. Although staff reported that bed hold forms were typically given to emergency personnel, there was no evidence in the clinical records that the residents or their representatives received the notifications, and the DON acknowledged discarding the policies after scanning related paperwork.
A resident with severe cognitive impairment and Alzheimer's disease, who required supervision due to impaired safety awareness and risk of elopement, was left unattended at a hospital waiting area during a medical appointment. The facility's transport driver, believing a family member would meet the resident, departed after leaving the resident with a receptionist, despite no family being present. The resident's need for supervision was documented in her care plan, and the facility lacked a policy on resident transportation.
Two residents receiving psychotropic medications did not have appropriate gradual dose reductions or documented clinical contraindications, and their care plans lacked identification of targeted behavioral symptoms for medication use. Pharmacy recommendations for dose reduction were declined by physicians without detailed risk-benefit analyses, and documentation of delusions and hallucinations was not resident-specific. Staff interviews and record reviews confirmed inconsistent and insufficient documentation related to the use of these medications.
Two residents were not re-offered or re-educated about pneumococcal vaccination after initially declining it upon admission, despite facility policy and CDC guidance requiring ongoing offerings. The Infection Preventionist confirmed that only influenza and COVID-19 vaccines were offered annually, not pneumococcal, and documentation lacked evidence of further vaccine offerings after admission.
The facility failed to provide appropriate dementia services, as residents were not engaged in meaningful activities or offered sensory materials. Staff struggled to modify activities to meet cognitive levels, and observations showed residents sitting idly without interaction. Clinical records indicated severe cognitive impairments, but the facility's program did not adequately address these needs.
A resident with severe cognitive impairment and respiratory conditions was not properly monitored for oxygen therapy, leading to a deficiency in care. Observations showed the resident's oxygen humidification was inadequate, and the portable oxygen tank was empty, resulting in the resident not receiving continuous oxygen. Staff interviews revealed inconsistencies in understanding oxygen titration orders, and facility policies for maintaining oxygen equipment were not followed.
Failure to Follow Physician-Ordered Pureed Diets for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered therapeutic pureed diets to residents with specific dietary orders. Resident C had diagnoses including encephalopathy, malignant neoplasm of the colon, diverticulosis of the large intestine, and GERD, with current orders for fortified foods with a pureed texture. The resident’s care plan identified potential nutritional risk related to diagnoses and inadequate nutrient or energy intake, with an intervention to provide the ordered diet, supplements, medications, and adaptive equipment. During a meal observation, Resident C was served a tray with pureed food but also a whole, non-pureed brownie. The resident independently used a fork to eat a bite of the brownie, and a CNA verbally encouraged the resident to eat the brownie, despite the pureed diet order. Resident F had dementia and dysphagia in the pharyngeal phase, with current orders for fortified foods with a pureed texture and a care plan noting risk for malnutrition and the need for assistance with meals and provision of the ordered diet. During a meal observation, Resident F was also served a tray with pureed food and a whole, non-pureed brownie. A QMA asked if the resident was ready for the brownie, placed it in front of him, and offered help cutting it, which the resident declined. The resident then cut and ate pieces of the brownie. Later, as the resident struggled with brownie crumbs, the QMA checked on him and then removed the plate when he indicated he was finished. In an interview, the QMA stated she did not know whether the brownie was considered a pureed item. The Dietary Manager confirmed that pureed foods must be blended to a paste consistency and that whole brownies are not considered pureed. The facility’s policy on maintaining current orders in the electronic clinical record was stated to apply to dietary orders as well.
Failure to Supervise Nebulizer Treatment for Non-Authorized Self-Administering Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide supervised nebulizer treatments to a resident who had not been authorized to self-administer medications. During an observation, the resident was found lying in bed holding a nebulizer mask to her face with the nebulizer machine running on the bedside table and no staff present. A CNA briefly entered the room to state she would return to provide care, then left, and the nebulizer continued without nursing supervision until the MDS Coordinator entered and turned off the machine. The MDS Coordinator stated she did not know if the resident could self-administer nebulizer treatments and noted the resident’s nurse was on break. Record review showed the resident had diagnoses including unspecified dementia without behavioral disturbance and a physician’s order for ipratropium-albuterol nebulizer treatments three times daily for COPD, with no order authorizing self-administration of nebulizer treatments. The resident’s progress notes and care plan contained no documentation related to self-administration of nebulization. An RN later stated the resident was not able to self-administer but that he typically allowed her to complete nebulizer treatments without staff present due to other medication priorities. A self-administration assessment, dated with an observation several days earlier but completed on the same day as the survey review, indicated it was appropriate for the resident to self-administer ipratropium-albuterol and store the medication in her room; however, this assessment was not yet reflected in the care plan or progress notes at the time of the observation. Facility policy required staff to remain with a resident during nebulizer treatment unless the resident had been assessed and authorized to self-administer.
Failure to Follow Hand Hygiene and Linen Handling Practices During Perineal Care
Penalty
Summary
The deficiency involves a failure to implement proper infection prevention and control practices during incontinence and personal care for one resident. During an observed care episode, a CNA and a QMA donned gloves and uncovered the resident, whose incontinence brief was soiled. The QMA provided perineal care, removed the soiled brief from under the resident, retrieved a trash can, and disposed of the brief, but did not change gloves or perform hand hygiene after completing perineal care. With the same gloves still on, the QMA then assisted the resident with dressing, helped the resident sit on the side of the bed, transferred the resident into a wheelchair, and handled the resident’s oxygen tubing and nasal cannula, placing it on the resident’s face and nose. During the same care episode, while the QMA and CNA were assisting the resident, the CNA placed a soiled bath blanket onto the carpeted floor while making the resident’s bed, despite a facility policy stating that soiled linen should not be placed on furniture or the floor. The CNA later stated the blanket was only slightly soiled and that she would not normally place soiled linens on the floor, and the QMA acknowledged he had forgotten to change gloves and would normally do so after providing perineal care. The resident involved had diagnoses including Parkinson’s disease and dementia, was moderately cognitively impaired per a recent MDS, was dependent for toileting hygiene, required substantial to maximal assistance with personal hygiene, and was always incontinent of bladder and frequently incontinent of bowel. During the exit conference, the Executive Director indicated there was no facility policy specifically related to changing gloves after providing perineal care.
Failure to Prevent Elopement of Resident with Dementia from Secured Unit
Penalty
Summary
A resident with a diagnosis of dementia, agitation, and a history of exit-seeking behaviors was admitted to the facility and initially placed on one-to-one supervision with a wander guard device applied to his ankle. The resident was assessed as an elopement risk, and his care plan included monitoring for wandering triggers and the use of a secured unit if needed. After several days of one-to-one supervision, the resident was transferred to a secured dementia unit, at which point the wander guard and one-to-one supervision were discontinued due to the unit's locked status. Despite residing on the secured unit, the resident was able to exit the facility when a visitor entered the code to the egress door and held it open, allowing the resident to leave unsupervised. Staff interviews and video footage confirmed that the resident exited the building with the assistance of the visitor and was not immediately noticed as missing by facility staff. The resident was unaccounted for outside the facility for approximately 50 minutes, during which time he walked across a four-lane highway and traveled nearly 0.7 miles away from the facility. The resident was eventually located by a staff member who was arriving for work and observed him walking near a park. The staff member returned the resident to the facility by car. At the time of the incident, the facility's policy required staff to attempt to prevent disoriented residents from exiting, but the policy was not effectively implemented in this case, resulting in the resident's unsupervised elopement.
Failure to Provide Bed Hold Policy Notification During Hospital Transfers
Penalty
Summary
The facility failed to provide required bed hold policy notifications to two residents who were discharged to the hospital. In both cases, the residents were cognitively intact and had been discharged with a return anticipated. For one resident, there was no documentation in the clinical record that a bed hold notice was provided or offered, despite the transfer/discharge form indicating that the bed hold policy should be attached. Nursing notes only indicated that appropriate documentation was sent with emergency personnel, but did not specify that the bed hold notice was included or received by the resident. For the second resident, although nursing notes stated that the notice of transfer and bed hold forms were completed, there was no indication in the clinical record of who received the bed hold form. Staff interviews revealed that the bed hold policy was typically given to emergency personnel to take to the hospital, but not directly to the resident or their representative, and that documentation of this process was lacking in the clinical record. The Director of Nursing admitted to discarding the bed hold policies after scanning the notice of transfer/discharge, resulting in the absence of these documents in the residents' records.
Resident with Dementia Left Unattended During Medical Appointment
Penalty
Summary
A resident with severe cognitive impairment and Alzheimer's disease was transported by facility staff to a hospital for a scheduled medical procedure. The resident, who had a care plan indicating impaired safety awareness and risk of elopement, was left unattended in the hospital waiting area without facility or family supervision. The transport driver reported that he was told by a dementia unit leader that the resident's family would meet her at the hospital. Upon arrival, the hospital receptionist mentioned the family would be coming, but no family member was present. The driver left the resident with the receptionist and departed to transport another resident, despite being aware that residents should not be left unsupervised unless a family member is present. The resident's family only became aware of the situation when a family friend saw the resident alone at the hospital and notified them, prompting a family member to arrive and stay with the resident during the procedure. The resident's clinical record and care plan documented her need for supervision due to dementia and impaired decision-making. The facility did not have a policy regarding transportation of residents at the time of the incident.
Failure to Ensure Gradual Dose Reduction and Documentation for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents receiving psychoactive medications had appropriate gradual dose reductions (GDR) or documented clinical contraindications, and did not identify or document targeted behavioral symptoms for the use of psychotropic medications for two of five residents reviewed. For one resident with diagnoses including delusional disorder, heart failure, obesity, and sleep apnea, the clinical record showed ongoing use of sertraline, quetiapine, and trazodone. Pharmacy consultant recommendations for GDR were declined by the physician without a resident-specific risk-benefit analysis or clear statement of contraindication. The care plans lacked identification of targeted behaviors for the use of these medications, and documentation of delusions and hallucinations was not resident-specific. Observations and staff interviews confirmed the presence of hallucinations and delusions, but the clinical record did not contain specific or consistent documentation of these symptoms. Another resident with dementia, psychotic and mood disturbances, and anxiety was prescribed multiple psychotropic medications, including amitriptyline, duloxetine, and quetiapine. Pharmacy recommendations for GDR were also declined by the physician, with only a general statement that "risk outweighs benefit" and no detailed risk-benefit analysis. The care plans did not specify targeted behaviors or symptoms for the use of these medications. Documentation in the medication administration record indicated delusions, but lacked resident-specific details. Staff interviews revealed that the resident had not recently reported hallucinations or delusions, though some behaviors such as packing belongings and attempting to take a roommate's items were noted. The clinical record did not contain specific documentation of hallucinations or delusions, and the resident's family had previously refused GDRs, though some changes were eventually made. The facility's policy required that psychotropic medications be used only when medically necessary, with appropriate documentation and ongoing efforts to reduce dosages unless contraindicated. However, in both cases, the required documentation of medical necessity, targeted behaviors, and resident-specific contraindications for GDR was lacking. The deficiency was identified through observation, interview, and record review, demonstrating a failure to comply with regulatory requirements for the use of unnecessary drugs and psychotropic medication management.
Failure to Offer and Educate on Pneumococcal Vaccines per CDC Guidance
Penalty
Summary
The facility failed to offer and educate residents regarding pneumococcal vaccines in accordance with CDC guidance for two out of five residents reviewed for infection control. One resident, with diagnoses including severe cognitive impairment and dementia, had a historical administration of the pneumococcal vaccine prior to admission and declined the vaccine upon admission after being provided education. However, there was no documentation of the vaccine being offered again since admission. Another resident, who was cognitively intact and had a history of paraplegia and other conditions, also had a historical pneumococcal vaccine prior to admission and declined the vaccine upon admission, with no further documented offerings since that time. During an interview, the Infection Preventionist stated that influenza, COVID-19, and pneumococcal vaccines are offered upon admission, with only influenza and COVID-19 vaccines being offered annually thereafter. The facility's policy indicated that pneumococcal vaccines should be offered per CDC recommendations and physician orders, but the records reviewed did not show ongoing offerings or education regarding the pneumococcal vaccine after the initial admission period for the affected residents.
Deficiency in Dementia Care Services
Penalty
Summary
The facility failed to provide appropriate dementia services to enhance the quality of life for residents on a dementia unit. Observations revealed that residents were not offered meaningful and purposeful activities or sensory materials. During multiple observations, residents were seen sitting idly without engagement or interaction from staff. Sensory items such as books, magazines, puzzles, games, art materials, and manipulative devices were not made available to the residents, despite being present in the facility. Interviews with staff, including an LPN and the Activity Assistant, highlighted a lack of understanding and training in providing suitable activities for residents with severe cognitive impairments. The Activity Assistant struggled to modify activities to meet the cognitive levels of the residents, often asking questions that required abstract reasoning, which the residents could not answer. Activities were not adjusted to accommodate the residents' cognitive limitations, and there was a lack of tactile or visual aids to support engagement. The clinical records of the residents involved indicated severe cognitive impairments, visual and hearing impairments, and a need for engagement in meaningful activities. Despite these documented needs, the facility's program did not adequately address them. The facility's policy and activity calendar suggested a structured program, but observations showed a lack of implementation and adaptation to the residents' needs. The Administrator and staff were unsure how to modify activities to suit the residents' cognitive abilities, leading to a deficiency in providing appropriate dementia care services.
Deficiency in Respiratory Care Due to Improper Oxygen Management
Penalty
Summary
The facility failed to properly monitor and maintain oxygen therapy for a resident, leading to a deficiency in respiratory care. Observations revealed that the resident was receiving oxygen via nasal cannula connected to an oxygen concentrator set at four liters per minute, but the humidification canister was either low or empty, preventing proper humidification. The resident, who had severe cognitive impairment and required maximal assistance, was observed to be lethargic and not feeling well, yet there was no provider notification of the increased need for oxygen titration. The resident's clinical record indicated a history of chronic obstructive pulmonary disease (COPD), pneumonia, heart failure, and ischemic cardiomyopathy. Physician orders for oxygen therapy were not consistently followed, as the resident's oxygen was set at four liters per minute without proper humidification, and the portable oxygen tank was found empty while the resident was in a wheelchair. Staff interviews revealed a lack of understanding and adherence to oxygen titration orders, with discrepancies in how high oxygen could be titrated without specific parameters. Facility policies required the use of humidification for oxygen orders at four liters per minute and specified procedures for maintaining oxygen equipment. However, these policies were not followed, as evidenced by the empty humidification canister and the resident's connection to an empty portable oxygen tank. The facility's failure to ensure continuous oxygen supply and proper equipment maintenance contributed to the deficiency in respiratory care for the resident.
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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.
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Nursing homes near Anderson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Envive Of Anderson | 1.8 mi | ★★★★★ | 9 | 0 |
| Edgewater Woods | 2.9 mi | ★★★★★ | 8 | 0 |
| Waters Of Chesterfield Skilled Nursing Facility | 2.9 mi | ★★★★★ | 4 | 0 |
| Northview Health And Living | 3 mi | ★★★★★ | 19 | 0 |
| Beaumont Rehabilitation And Healthcare Center | 3 mi | ★★★★★ | 27 | 0 |
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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.