Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Village during CMS and state inspections, most recent first.
Uncovered Hair Observed in Kitchen Food Prep Area During kitchen observations, a Dietary Aide with facial hair was seen near the steamtable with his beard and mustache uncovered, and another Dietary Aide was seen with long loose hair extending below a hair net while the noon meal was being prepared and plated. The same issues were observed again later during meal service. The DM stated staff hair was to be kept covered in the kitchen, and the facility policy required hair and beard restraints to effectively cover all hair.
Unsecured Housekeeping/Electrical Room: The facility failed to keep a Housekeeping/Electrical room closed and locked when staff were not present. The open room, located near the main dining room and 300 hall, contained tools, electric wires, cleaning supplies, and maintenance equipment, and no staff were visible in the area during the observation. An FT entered the open room, and the ED stated 15 self-mobile cognitively impaired residents could have accessed it.
Failure to share dialysis records between the facility and the dialysis center for two residents receiving regular dialysis. Both residents had ESRD and were cognitively intact, and both were transported to dialysis on a recurring schedule. However, neither resident was sent with facility paperwork or returned with dialysis paperwork, and the clinical record lacked documentation showing communication between the facility and dialysis unit. The DON confirmed there was no written communication for either resident, despite the facility's dialysis agreement and policy calling for documented collaboration and communication.
Insulin pens were found in two medication carts without required open-date labels. An LPN observed that the pens should have been labeled when opened, and one pen also lacked the resident’s name. The DON stated the FlexPens should have been dated at the time they were opened, and the facility policy required opened injectable meds to be dated.
A resident with vascular dementia and guardian consent for flu and pneumococcal vaccines had no vaccination records in the EHR. The DON confirmed there were no records for either vaccine and stated the resident should have received them as recommended. Facility policy and CDC guidance reviewed by surveyors indicated the resident was eligible for annual influenza vaccination and age-appropriate pneumococcal vaccination.
A resident with vascular dementia had no recent COVID-19 booster documented in the EHR after admission, despite a guardian consent form for recommended COVID-19 vaccinations and boosters. The DON stated the resident should have received at least one booster after admission, and the facility policy required residents to be offered COVID-19 vaccines and boosters based on vaccination history and consent.
A resident with multiple medical conditions left the facility against medical advice after expressing dissatisfaction with care. Although the resident was informed of the risks, staff failed to document the details of the discharge in the medical record as required by facility policy.
The facility failed to protect resident trust accounts, resulting in unauthorized withdrawals for six residents. Discrepancies in signatures and illegible signatures on withdrawal slips were found, with staff signatures being forged. The facility could not identify those responsible for the misappropriation.
A facility failed to maintain a safe environment by leaving a rubber hose on the floor in a walkway, creating a tripping hazard for residents. The hose was observed in the 500-hall between the resident pantry and lounge, with no staff or caution signs present. Interviews revealed staff were unaware of the need for caution signs, and the Administrator admitted the hose should not have been there. The facility's safety policies were not adhered to, affecting 36 self-mobile residents.
A resident was observed with their call light out of reach, hanging over the bed and on the floor. The ADON confirmed that the call light should have been accessible to the resident. The facility's policy on resident rights emphasizes the importance of access to communication and services.
A facility failed to notify the State Long-Term Care Ombudsman of a resident's transfers to emergency and psychiatric facilities. The resident, with severe cognitive impairment and other diagnoses, was transferred multiple times without the required written notification. Interviews revealed the facility lacked a policy for such notifications.
The facility failed to accurately document falls in the MDS assessments for two residents. One resident with Parkinson's disease and another with chronic obstructive pulmonary disease and dementia experienced multiple falls, which were not correctly recorded in their respective MDS assessments. The MDS Coordinator acknowledged the errors during interviews.
A resident with a high risk for pressure ulcers did not receive proper wound care as per physician's orders. The resident's right heel wound was observed uncovered on multiple occasions, despite orders to cleanse, apply collagen, and cover with gauze every three days. The ADON acknowledged the wound should have been wrapped, but it was not, contrary to the facility's Skin Management Program policy.
An unlocked treatment cart was found in the memory care unit without staff supervision, containing medicated treatments labeled to be kept out of reach. Interviews with an LPN and the Executive Director confirmed the cart should have been locked, as per facility policy. The unit housed 20 cognitively impaired, self-mobile residents.
A facility failed to maintain a homelike atmosphere in a resident's room, where a six-inch by six-inch hole in the drywall exposed wires above the room light. The issue persisted over several days, and the resident was unaware of how long it had been there. The Executive Director was not aware of the problem and noted the absence of a maintenance director.
Uncovered Hair Observed in Kitchen Food Preparation Area
Penalty
Summary
The facility failed to ensure foods were served in a sanitary and safe manner during kitchen observations. During a follow-up observation in the kitchen service area where the noon meal was being prepared and plated, Dietary Aide 7 was observed walking near the steamtable with facial hair approximately one-half inch in length above and below the lip area and at the upper cheek bone area, and the facial hair was not covered. Dietary Aide 8 was also observed in the same kitchen area wearing a white hair net that covered hair from above the ears and approximately three inches above the neckline to the top of the head, but multiple loose hairs approximately 12 to 18 inches in length were visible below the hair net. Hairs were pulled from behind both ears, resting on the chest area, and hanging from the neckline to the mid shoulder area, and these hairs were not covered. The same conditions were observed again later that day while the noon meal was being plated and served at the steamtable. Dietary Aide 7 again had uncovered facial hair in the kitchen service area, and Dietary Aide 8 again had uncovered loose hair below the hair net while working near the steamtable. During interview, the Dietary Manager stated staff's hair was to be kept covered while in the kitchen area. The facility's Culinary Personal Hygiene policy stated that all employees working in the culinary department must wear a clean hair restraint that effectively covers all hair, and employees with facial hair must wear a beard restraint that effectively covers all facial hair.
Unsecured Housekeeping/Electrical Room
Penalty
Summary
The facility failed to ensure potentially hazardous materials were kept secured and behind locked doors to prevent resident access. On 9/4/25, the Housekeeping/Electrical room near the main dining room and the 300 hall was observed with a posted sign stating "Not An Exit" and a keypad lock above the door handle, but the door was open. Inside the room were multiple tools, electric wires, cleaning supplies, and various maintenance equipment, and no staff were visible in the area during the observation. At 11:09 a.m. that same day, Floor Technician 6 was observed walking from the nurse's station area, past three occupied resident rooms, and into the open Housekeeping/Electrical room. During interview, Floor Technician 6 stated the door was to be kept closed and locked when no staff were in the area. On 9/5/25, the Executive Director also observed the room and stated the door was to be kept closed and locked when staff were not present. The Executive Director identified 15 self-mobile cognitively impaired residents who could have accessed the unlocked room, and provided the facility's Direct Supply Tels: Door's policy stating doors to hazardous areas shall be self-closing or automatic closing.
Failure to Share Dialysis Records Between Facility and Dialysis Center
Penalty
Summary
The facility failed to ensure dialysis medical records were shared between the facility and the dialysis center for 2 residents who required dialysis services. Resident 2 had diagnoses including end stage renal disease and dependence on renal dialysis, and the quarterly MDS indicated the resident was cognitively intact and required dialysis services. Resident 13 also had diagnoses including end stage renal disease and dependence on renal dialysis, and the admission MDS indicated the resident was cognitively intact and required dialysis services. Resident 2 reported that he was transported to dialysis on Tuesday, Thursday, and Saturday, but he had not taken any facility paperwork to the dialysis center and did not return with any paperwork from the dialysis center. LPN 5 stated Resident 2 was not sent with any facility paperwork and did not return with any paperwork from the dialysis center. The DON provided physician orders showing Resident 2 was to be transferred to the dialysis center every Tuesday, Thursday, and Saturday, and appointment administration histories showed repeated dialysis transports in August and September 2025. The clinical record lacked dialysis health-related documentation showing communication between the facility and the dialysis center had been shared. Resident 13 stated he was transported to dialysis on Tuesday, Thursday, and Saturday, but he had not been given any facility paperwork to take to the dialysis center and the dialysis center had not provided paperwork to return to the facility. The DON provided physician orders showing Resident 13 was to be transferred to the dialysis center every Tuesday, Thursday, and Saturday, and appointment administration histories showed repeated dialysis transports in August and September 2025. The clinical record lacked dialysis health-related documentation showing communication between the facility and the dialysis center had been shared. The DON stated the facility lacked any written communication between the facility and the dialysis center for Resident 2 and Resident 13, and the facility's dialysis agreement and policy stated that documented collaboration and communication between the facility and dialysis unit was to occur.
Insulin Pens Found Undated in Medication Carts
Penalty
Summary
The facility failed to ensure insulin was labeled with an open date for 2 of 2 medication carts observed, including the rehab cart and the skilled cart. During an observation on 9/3/25 at 8:35 a.m., an opened and used insulin FlexPen 100 units/ml was found in the rehab medication cart without a label showing the date it was opened. During an interview at that time, an LPN stated there was no label on the insulin and that it should have been labeled when opened. During an observation on 9/3/25 at 8:45 a.m., an opened and used insulin FlexPen 100 units/ml was found in the skilled unit medication cart without a label showing when it was opened, and it also lacked a label identifying the resident to whom it was prescribed. During an interview at that time, an LPN stated the pen had been opened and should have been labeled. Later, the DON stated the FlexPens should have been dated at the time they were opened, and the facility policy provided by the ED stated that an opened multidose vial of injectable medication should be dated and discarded within 28 days unless the manufacturer specifies otherwise.
Missed Influenza and Pneumococcal Vaccination Documentation
Penalty
Summary
The facility failed to follow current vaccine administration guidelines for influenza and pneumococcal vaccinations for one resident reviewed for vaccination records. Resident 10, who had unspecified vascular dementia and was admitted on 12/4/24, was [AGE] years old or older. On review of the resident’s electronic health record on 9/2/25, the preventative health section did not contain records of any influenza or pneumococcal vaccinations. On 9/4/25, the DON provided influenza and pneumococcal vaccination consent forms showing the resident’s guardian had consented to both recommended vaccines. During interview, the DON stated there were no records for Resident 10’s influenza or pneumococcal vaccinations and that the resident should have received them as recommended and requested with the guardian’s signed consent. The facility’s current influenza and pneumococcal policies were reviewed, and CDC guidance indicated annual influenza vaccination and age-appropriate pneumococcal vaccination were recommended for adults [AGE] years of age or older, including a dose of PCV 20 or PCV 21 when vaccination history is unknown.
Missed COVID-19 Booster Documentation and Administration
Penalty
Summary
The facility failed to follow current COVID-19 vaccine administration guidelines for 1 of 5 residents reviewed for vaccination records, identified as Resident 10. On 9/2/25, review of the resident’s clinical record showed the preventative health section in the electronic health record did not contain any recent COVID-19 booster vaccinations. The only vaccine documented was a historical COVID-19 vaccine from 2022 at a previous facility, and no subsequent vaccinations had been administered after the resident’s admission on 12/4/24. Resident 10’s diagnoses included unspecified vascular dementia, and the resident was [AGE] years old or older. On 9/4/25, the DON provided a COVID-19 vaccination consent form showing the resident’s guardian had consented to recommended COVID-19 vaccinations and boosters. During interview, the DON stated Resident 10 should have received at least one booster dose of COVID-19 after admission based on the immunization record. The facility’s policy, dated 12/2020 and identified as the current policy in use, stated residents are to be offered COVID-19 vaccinations upon admission based on vaccination history and are to receive additional doses and/or boosters for current consenting residents. A review of CDC guidance updated 7/2/25 indicated adults [AGE] years of age or older were to receive two or more doses of the 2024-2025 vaccination boosters.
Incomplete Documentation for Discharge Against Medical Advice
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate when the resident discharged against medical advice. A resident with diagnoses including acute osteomyelitis, acquired absence of right leg below knee, and diabetes left the facility with his sister against medical advice after expressing dissatisfaction with his care since admission. Although the resident had been informed of the risks associated with leaving against medical advice, there was no progress note in the clinical record documenting the details of the discharge. Interviews with the resident and the Director of Nursing (DON) confirmed that the resident and his sister notified staff as they were leaving, and the DON acknowledged that a nurse should have entered a progress note at the time of discharge. Review of the facility's policy indicated that documentation should include staff attempts to provide other options and information about the risks of leaving, but this documentation was missing from the resident's record.
Misappropriation of Resident Trust Funds
Penalty
Summary
The facility failed to safeguard resident trust accounts, leading to misappropriation of funds for six residents. During interviews and record reviews, it was discovered that cash withdrawals from these accounts were unaccounted for, with discrepancies in signatures and illegible signatures on withdrawal slips. For instance, Resident B, who was cognitively intact, had multiple withdrawals with signatures that did not match his own, and the facility could not identify the individuals who signed the slips. Similarly, Resident C's account showed withdrawals with mismatched signatures, and a family member reported a delinquency letter that did not align with their understanding of the account status. Other residents, including Residents D, E, F, and G, also had unauthorized withdrawals with illegible or forged signatures, and the facility was unable to determine who was responsible for these transactions. The investigation revealed that staff signatures on the withdrawal slips were forged, and the facility could not identify the individuals responsible for the misappropriation. The facility's policy was to provide an environment free from misappropriation of resident property, but this was not adhered to, resulting in the unaccounted withdrawal of funds from resident trust accounts.
Facility Fails to Eliminate Tripping Hazard in Walkway
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by the presence of a rubber hose used for fish tank maintenance left on the floor in a walkway area. This hose, approximately one inch in diameter and 25 feet in length, was observed in the middle of the walkway between the resident pantry and the resident lounge on the 500-hall. The hose was curled and raised above the floor at certain points, creating a potential tripping hazard. During the observation period, multiple residents were present in the lounge area, and no staff or caution signs were visible to alert residents of the hazard. Interviews conducted with staff revealed a lack of awareness and adherence to safety protocols. An LPN was unsure if caution signs were necessary, and the Administrator acknowledged that the hose should not have been placed in the walkway. The Director of Nursing Services confirmed that 36 of 56 self-mobile residents had access to the 500-hall, indicating a significant risk to resident safety. The facility's General Health and Safety Policies, which mandate the elimination or control of safety hazards, were not followed in this instance.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure reasonable accommodation of needs for one of the eight residents observed. During an observation, Resident 86 was found in bed with the call light hanging over the bed and on the floor, out of the resident's reach. In an interview conducted at the time of observation, the Assistant Director of Nursing (ADON) confirmed that the call light should have been within the resident's reach. The facility's policy titled Resident [NAME] of Rights, dated December 2017, was reviewed and indicated that residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the community.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide written notification to the Office of the State Long-Term Care Ombudsman regarding the transfer of a resident, identified as Resident 39, to other facilities. Resident 39, who was diagnosed with delusional disorder, severe dementia with agitation, and mood disturbance, was transferred multiple times to emergency and psychiatric facilities. These transfers occurred on several occasions in March, April, and May 2024, and were all initiated by the facility. The clinical records for Resident 39 did not contain documentation that the Ombudsman was notified of these facility-initiated transfers. Interviews with the Social Service Director and the Administrator confirmed that the Ombudsman had not been informed of the transfers, and the facility lacked a specific policy for notifying the Ombudsman about such transfers.
Inaccurate MDS Assessments for Falls
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents, leading to incorrect documentation of falls. Resident 35, diagnosed with Parkinson's disease, unsteadiness on feet, repeated falls, generalized muscle weakness, syncope and collapse, and difficulty in walking, experienced an unwitnessed fall on 7/9/24, resulting in left shoulder pain that required x-rays. However, the Quarterly MDS assessment dated 8/7/24 inaccurately indicated that Resident 35 had not experienced any falls since the previous assessment on 5/10/24. The MDS Coordinator acknowledged during an interview that the assessment should have reflected the falls. Similarly, Resident 92, with diagnoses including chronic obstructive pulmonary disease, unspecified dementia, generalized muscle weakness, and age-related physical debility, had multiple falls documented in July 2024. These included a witnessed fall near a nursing station on 7/7/24, another witnessed fall on 7/13/24, and an unwitnessed fall on 7/21/24. Despite these incidents, the Significant Change MDS assessment dated 7/22/24 incorrectly stated that Resident 92 had not experienced any falls since the prior assessment on 5/19/24. The MDS Coordinator confirmed that the assessment should have included the falls, despite the facility's adherence to RAI guidelines for MDS assessments.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a pressure ulcer on her right heel. Observations on multiple occasions revealed that the wound was not covered with gauze as per the physician's order, which specified cleansing the heel with normal saline, applying collagen to the wound bed, and covering it with gauze every three days. The resident, who had a very high risk for pressure ulcers as indicated by a recent Braden Score, was observed with an uncovered wound on three separate days. The Assistant Director of Nursing acknowledged that the wound should have been wrapped but was unsure why it was not. The facility's Skin Management Program policy, intended to prevent and treat pressure ulcers, was not adhered to in this case.
Unlocked Treatment Cart in Memory Care Unit
Penalty
Summary
The facility failed to ensure that a treatment cart was locked and secured during a medication administration pass observation on the memory care unit. An unlocked treatment cart was observed without any staff present, and multiple residents were seen wandering around the unit. The cart contained medicated treatments, including Nystatin Topical Cream, Vagisil Cream, and Aquaphor Healing Ointment, all labeled with instructions to keep out of reach. This observation was made between 9:00 a.m. and 9:15 a.m. on 9/6/24. Interviews conducted with LPN 3 and the Executive Director confirmed that the treatment cart should have been locked. The Director of Nursing provided a policy titled "Storage and Expiration Dating of Medications and Biologicals," which indicated that all medications and biologicals should be securely stored in a locked cabinet or cart, inaccessible to residents and visitors. The memory care unit housed 20 out of 25 cognitively impaired, self-mobile residents, highlighting the importance of securing the treatment cart.
Facility Fails to Maintain Homelike Atmosphere Due to Exposed Wires
Penalty
Summary
The facility failed to ensure a homelike atmosphere in one of the rooms observed, specifically room [ROOM NUMBER], where a six-inch by six-inch hole in the drywall was found above the resident's room light. This hole exposed wires, posing a potential safety hazard. The issue was first observed during a facility tour and was noted on multiple subsequent days without any change. Resident 86, who occupied the room, was unaware of how long the hole had been present. During an interview, the Executive Director stated she was not aware of the hole and mentioned that the facility did not have a maintenance director at the time.
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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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