Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Skilled Nursing Facility during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment fell and sustained injuries after a CNA attempted to use a Hoyer lift without the required assistance of a second staff member. The resident became agitated during the transfer, leading to a fall and hospitalization. The care plan, which required two staff members for transfers and specific actions if the resident became combative, was not followed.
A resident requiring a Hoyer lift with two staff members for transfers fell and sustained injuries when a CNA attempted the transfer alone, contrary to facility policy. The resident, who had dementia and major depressive disorder, became agitated during the transfer, leading to the fall. Staff interviews confirmed the CNA's awareness of the policy but proceeded due to the resident's distress.
The facility failed to ensure that a resident was offered or administered the Pneumococcal Vaccine as required. The resident, who had severe cognitive impairment and a history of COPD and dementia, was eligible for the vaccine upon admission but did not receive it. The facility did not follow up with the healthcare proxy or adhere to its own vaccination policy.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to implement and follow the care plan interventions for a resident who required the use of a Hoyer lift with the assistance of two staff members for all transfers. On the day of the incident, the resident became agitated while waiting to be transferred back to bed. Despite knowing the requirement for two staff members, CNA #1 attempted to lift the resident using the Hoyer lift without waiting for the second staff member, CNA #2, to assist. This action was taken in response to the resident's complaint of discomfort, but it resulted in the resident sliding out of the Hoyer lift pad and falling to the floor. The resident, who had a history of dementia and major depressive disorder, was severely cognitively impaired and dependent on staff for care. The care plan specified that if the resident became combative, staff should reassure the resident, leave, and return later to attempt care again. However, CNA #1 did not follow this protocol and proceeded with the lift, exacerbating the resident's agitation and leading to the fall. The fall resulted in significant injuries, including a scalp laceration, head injuries, and fractures, necessitating the resident's transfer to the hospital emergency department. The incident was documented in the facility's fall investigation and reported through the Health Care Facility Reporting System. Interviews with staff confirmed that the required protocol for using the Hoyer lift was not followed, contributing to the resident's fall and subsequent injuries.
Removal Plan
- Nursing immediately assessed Resident #1 for injuries, 911 was initiated and he/she was transferred to the Hospital Emergency Department, he/she returned within 24 hours.
- The Staff Development Coordinator initiated staff education on the use of mechanical lifts and all nursing staff were required to complete an additional Mechanical Lift competency that included return demonstration.
- Daily visual observation audits by Nursing administration on the day and evening shifts were initiated to ensure two staff members were present for Hoyer lift transfers. Observation Audits will continue.
- Resident #1 returned to the facility and his/her Comprehensive Care Plan was reviewed and revised.
- The Facility recognized that all residents have the potential to be affected by the same deficient practice, and the DON completed a facility-wide audit for all Residents requiring Hoyer lifts which included a review of their Comprehensive Care Plans.
- The Director of Rehabilitation completed facility-wide audit of all residents requiring a Hoyer lift, to ensure the correct Hoyer pads were being used on all residents according to manufacturer's guidelines.
- The area of concern and data collected, was presented at the Facility's Quality Assurance Performance Improvement Committee Meeting, and a QI project was developed.
- The Administrator, the Director of Nursing and/or their designees will be responsible for overall compliance.
Failure to Ensure Safe Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure the safety of a resident who required the use of a Hoyer lift with the assistance of two staff members for all transfers. On the day of the incident, a Certified Nurse Aide (CNA) initiated a Hoyer lift transfer for the resident from their wheelchair without the presence of another staff member. This action was against the facility's policy, which mandates that two staff members must be present during such transfers. As a result, the resident slid forward in the Hoyer lift pad and fell onto the floor, sustaining multiple injuries including a scalp laceration, head injuries, and fractures. The resident involved had been admitted to the facility in March 2017 and had diagnoses including dementia and major depressive disorder. The resident's care plan specified the need for a Hoyer lift with two staff members for transfers, and the behavior care plan advised staff to reassure the resident and return later if they resisted activities of daily living. During the incident, the resident became agitated and yelled about discomfort, prompting the CNA to lift the resident slightly to relieve pressure, which led to the fall. Interviews with staff revealed that the CNA was aware of the requirement for two staff members during Hoyer lift transfers but proceeded alone due to the resident's distress. The CNA demonstrated how the resident fell during the surveyor's investigation. Other staff members, including another CNA and nurses, confirmed the sequence of events and the resident's condition after the fall. The facility's investigation did not initially highlight the absence of a second staff member during the transfer, which was a critical factor in the incident.
Removal Plan
- Nursing immediately assessed Resident #1 for injuries, 911 was initiated and he/she was transferred to the Hospital Emergency Department, he/she returned within 24 hours.
- The Staff Development Coordinator initiated staff education on the use of mechanical lifts and all nursing staff were required to complete an additional Mechanical Lift competency that included return demonstration.
- Daily visual observation audits by Nursing administration on the day and evening shifts were initiated to ensure two staff members were present for Hoyer lift transfers. Observation Audits will continue.
- Resident #1 returned to the facility and his/her Comprehensive Care Plan was reviewed and revised.
- The Facility recognized that all residents have the potential to be affected by the same deficient practice, and the DON completed a facility-wide audit for all Residents requiring Hoyer lifts which included a review of their Comprehensive Care Plans.
- The Director of Rehabilitation completed facility-wide audit of all residents requiring a Hoyer lift, to ensure the correct Hoyer pads were being used on all residents according to manufacturer's guidelines.
- The area of concern and data collected, was presented at the Facility's Quality Assurance Performance Improvement Committee Meeting, and a QI project was developed.
- The Administrator, the Director of Nursing and/or their designees will be responsible for overall compliance.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that the Pneumococcal Vaccination was offered to and/or administered as required to one resident out of a sample of 18 residents. Specifically, the facility did not provide documentation that Resident #51 was offered the Pneumococcal Vaccine or did not receive it due to medical contraindication or refusal. The resident was not up to date with their Pneumococcal vaccination status and was eligible to receive a dose upon admission to the facility in February 2023. However, there was no evidence that the vaccine was administered or that the resident's healthcare proxy was consulted regarding the vaccination status. Resident #51, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Dementia, had a previous dose of Pneumococcal Polysaccharide Vaccine (PPV) administered on January 1, 1998. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment, and the healthcare proxy was invoked due to dementia. Despite having a physician's order for the Pneumococcal vaccine, the section of the Immunization Record Information Form related to the Pneumococcal vaccination was left blank, and the Infection Preventionist (IP) did not follow up with the healthcare proxy. During interviews, the IP acknowledged that the facility was not in compliance with Pneumococcal vaccination requirements and had been focusing on COVID-19 booster administration instead. The facility physician confirmed that the protocol for Pneumococcal vaccination should have been followed, and Resident #51 should have received a dose of PCV20 to be considered up to date. The facility's failure to adhere to its own policy and CDC guidelines resulted in the deficiency noted in the report.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carlyle House | 1.4 mi | ★★★★★ | 2 | 0 |
| Casa De Ramana Rehabilitation Center | 1.5 mi | ★★★★★ | 0 | 0 |
| St Patrick's Manor | 2.7 mi | ★★★★★ | 0 | 0 |
| Eliot Center For Health And Rehabilitation | 2.8 mi | ★★★★★ | 1 | 0 |
| Waterview Lodge Llc, Rehabilitation & Healthcare | 3.1 mi | ★★★★★ | 15 | 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.