Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Bethel Nursing Home Company Inc during CMS and state inspections, most recent first.
The facility did not maintain documentation or provide evidence that influenza and pneumococcal vaccines were offered, education was provided, or staff had the opportunity to consent or decline. Interviews with the Infection Preventionist and DON confirmed that vaccination status was not tracked and no master list was maintained.
Surveyors identified that the facility did not provide documentation of COVID-19 vaccine screening, administration, declination, or education for ten staff members, including CNAs, an LPN, an RN supervisor, dietary, housekeeping, and therapy staff. Interviews with the Infection Preventionist and DON confirmed that COVID-19 vaccinations had not been offered to staff, and no explanation was provided for this omission.
The facility did not ensure that CNAs received the mandatory twelve hours of annual in-service education or annual performance evaluations. Four out of five CNAs did not meet the in-service requirement, and none had documented performance reviews, as confirmed by staff interviews and record review.
Surveyors found expired, unlabeled, and improperly stored food items in multiple storage areas, as well as dishwashing equipment that failed to reach required sanitation temperatures. Staff, including the Food Service Director and CNAs, were observed not following hand hygiene protocols while serving meals, such as not changing gloves or using hand sanitizer after touching residents or their own face. These actions did not comply with facility policies for food safety and infection control.
A resident with multiple chronic conditions and requiring substantial assistance was repeatedly found with their call bell out of reach, despite facility policy and care plan directives. The resident reported being unable to locate the call bell and had to call out for help when assistance was needed. Staff confirmed the call bell was not checked during the shift and was displaced during routine care activities.
A resident with multiple medical conditions reported missing labeled clothing, which was brought to staff attention by the resident's spouse. The required Missing Item Report was not completed, and no investigation or follow-up occurred, as key staff including the Director of Housekeeping, Social Work, and DON were unaware of the incident.
A resident with significant mobility and cognitive impairments developed a reddened area behind the left ankle, which was observed by a representative and an LPN. The LPN applied bacitracin without a physician order, failed to report the skin change to the Unit Manager RN or physician, and did not follow up on the condition, resulting in care that did not meet professional standards or facility policy.
A resident with severe cognitive impairment and aspiration risk was fed by a privately hired, unqualified companion aide, contrary to facility policy requiring only certified staff to provide such care. Facility staff and the DON were unaware that the companion aide was providing feeding assistance, and the aide was not supervised or trained by the facility.
A resident with multiple health conditions experienced significant unplanned weight loss due to inconsistent monitoring and lack of assistance or encouragement with meals. Staff failed to accurately document food intake, were unaware of the resident's nutritional needs, and did not follow care plan interventions or facility policy regarding nutrition and hydration support.
Surveyors found that a resident with severe cognitive impairment was given crushed medications labeled 'do not crush' and received an inaccurately measured dose of Metamucil, as an LPN used a regular spoon instead of a measuring tool. These actions resulted in a medication error rate above the 5% threshold.
Surveyors identified expired medications and medical supplies in a medication storage room, including omeprazole, blood glucose monitoring products, and various needles, which were not removed as required by facility policy. Staff interviews revealed that checks for expired items were incomplete, with some areas of the storage room not being inspected, leading to expired drugs and supplies remaining accessible.
Failure to Document and Track Staff Vaccinations for Influenza and Pneumococcal Disease
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as required, specifically regarding the documentation and administration of influenza and pneumococcal vaccinations for staff. During the recertification survey, it was found that for five staff members reviewed for influenza vaccination, there was no documentation that the vaccine was offered, that education was provided, or that staff had the opportunity to consent or decline. Additionally, for ten staff members reviewed for pneumococcal vaccination, there was no documentation of the vaccine being offered, education provided, or consent/declination recorded. The facility also lacked a policy for pneumococcal vaccination. Interviews with the Infection Preventionist and the Director of Nursing revealed that there was no master list maintained for staff vaccination status, and that the process for tracking and offering vaccinations was not being followed. The Infection Preventionist stated that consents and declinations were forwarded to Human Resources when obtained, but no comprehensive tracking was in place. The Director of Nursing confirmed that vaccine information was sent offsite for new hires, but pneumococcal status was not tracked, and no ongoing record of staff vaccinations was maintained.
Failure to Document and Offer COVID-19 Vaccination to Staff
Penalty
Summary
Surveyors found that the facility failed to maintain infection control prevention practices related to COVID-19 vaccination for all staff. Specifically, there was no documentation provided for screening, administration, declination, or education regarding the COVID-19 vaccine for ten staff members, including certified nurse aides, a licensed practical nurse, a registered nurse supervisor, dietary and housekeeping staff, and therapy staff. The facility's COVID policy required newly hired staff to provide vaccination information and, if unvaccinated or not up to date, to receive education and be offered the vaccine. However, during the recertification survey, the facility was unable to produce any documentation showing that these steps had been followed for the staff reviewed. Interviews with the Infection Preventionist and the Director of Nursing confirmed that the facility had not been offering the COVID-19 vaccine to staff, and neither could provide a reason for this lapse. The Director of Nursing, who had been at the facility for several months, was unaware of any COVID-19 vaccinations being offered to staff during their tenure. This lack of action and documentation was found to be out of compliance with the facility's own policy and regulatory requirements.
Failure to Provide Required CNA In-Service Education and Performance Evaluations
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) received the required twelve hours of in-service education annually, as well as annual performance evaluations based on individual job performance. Review of facility training records showed that four out of five CNAs did not meet the mandatory twelve hours of in-service education in the past year. Additionally, none of the five sampled CNAs had documented evidence of an annual performance review. Specific examples included one CNA who received only 10.25 hours of in-service, another who received none, and another who received only 3 hours, all without performance evaluations. Interviews with the Director of Nursing (DON) and the Administrator revealed that performance evaluations for CNAs had not been conducted, and the DON was unaware of the deficiency until reviewing the records. The Administrator also stated they were not aware that CNA performance evaluations were not being completed. The findings were confirmed through staff interviews and review of facility documents, indicating noncompliance with regulatory requirements for CNA training and evaluation.
Deficient Food Storage, Dishwashing, and Hand Hygiene Practices
Penalty
Summary
Surveyors identified multiple failures in food storage, preparation, and service that did not comply with professional standards and facility policies. Expired food items were found in the dry pantry, walk-in refrigerator, freezer, and basement pantry, including bags of marshmallows, a jar of clam base, frozen chicken pot pies, and a jar of maraschino cherries. Additionally, unlabeled and undated food items, such as a container of chicken and opened bags of cornbread stuffing, biscuit mix, and dried pasta, were stored improperly. Individual cups of applesauce, pudding, and salads in the refrigerator were also not labeled or dated as required by policy. Dishwashing procedures were not maintained according to required temperature standards. Observations showed that the dish machine's wash and rinse temperatures were below the acceptable thresholds, with wash temperatures recorded at 148 degrees F and rinse temperatures at 150 and 154 degrees F, which did not meet the facility's policy of at least 150 degrees F for wash and 180 degrees F for rinse. The Food Service Director and Regional Food Service Director acknowledged the issue, and it was noted that the heat booster in the dish machine had been condemned, leading to a switch to chemical sanitization. Staff were observed not following proper hand hygiene protocols during meal service. The Food Service Director, while wearing disposable gloves, touched residents, their own neck, and food cart handles, and then continued to serve food without changing gloves or using hand sanitizer. Certified Nurse Aides were also seen touching residents and their own face masks, then handling food and serving meals without performing hand hygiene between tasks. The Director of Nursing confirmed that staff were expected to sanitize their hands whenever switching tasks, but this was not consistently followed.
Call Bell Inaccessibility for Dependent Resident
Penalty
Summary
The facility failed to ensure that the call bell system was accessible for a resident with diagnoses including depression, diabetes mellitus, and chronic obstructive pulmonary disease. The resident was cognitively intact but required substantial assistance with mobility and was dependent on staff for toileting hygiene and transfers. The facility's policy required that each resident have a call bell at bedside within reach, and the resident's care plan specifically directed that the call bell be within reach at all times. However, during multiple observations over several days, the resident was found lying in bed with the call bell on the floor and out of reach. The resident reported being unable to find the call bell and stated a preference for having it next to them. On one occasion, the resident indicated that when they needed assistance and could not find the call bell, they resorted to calling out for staff. A Certified Nurse Aide confirmed that the call bell was not within reach and was found behind a folded floor mattress, attributing its displacement to staff activity during breakfast service. The aide also acknowledged not having checked the call bell since the beginning of the shift, contrary to facility policy.
Failure to Investigate and Document Missing Resident Property
Penalty
Summary
The facility failed to ensure a resident's right to be free from misappropriation of personal property when a cognitively intact resident with multiple medical diagnoses, including polyneuropathy, peripheral vascular disease, and anxiety disorder, reported missing several golf shirts. The resident's spouse initially reported the missing items to the Unit Manager RN, who stated they relayed the information to the Director of Housekeeping but did not complete the required Missing Item Report form. The spouse received no follow-up or reimbursement, and the missing items, which were labeled, remained unaccounted for. Interviews with facility staff revealed that the Director of Housekeeping did not receive any report or communication regarding the missing items and therefore did not initiate an investigation. The Director of Social Work and the Director of Nursing were also unaware of the missing property. The facility's policy required immediate action and documentation when items were reported missing, but this process was not followed, resulting in a lack of investigation and communication with the resident and their representative.
Failure to Report and Appropriately Manage Change in Skin Condition
Penalty
Summary
Licensed Practical Nurse #1 failed to report a change in a resident's skin condition, as required by facility policy and professional standards of practice. The resident, who had diagnoses including cerebral infarction, flaccid hemiplegia, and vascular dementia, was dependent on staff for all activities of daily living and was at risk for skin breakdown. During a routine observation, the resident's representative noticed a reddened area behind the left ankle and reported it to the LPN, who also observed the skin change. The LPN applied bacitracin to the area and made a note to inform the Unit Manager RN but forgot to do so. No follow-up assessment or notification to the physician or Unit Manager RN occurred after the initial observation. Subsequent interviews confirmed that the Unit Manager RN was not informed of the skin change, and the Director of Nursing stated that any observed changes in skin status should be escalated immediately for assessment and physician notification. The LPN also applied bacitracin without a physician's order, contrary to facility policy. The failure to report the skin change and to obtain appropriate orders resulted in the resident not receiving care consistent with professional standards and facility protocols.
Unqualified Companion Aide Provided Feeding Assistance to High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who was at risk for aspiration. The resident, who had diagnoses including metabolic encephalopathy, altered mental status, and failure to thrive, was assessed as severely cognitively impaired and required partial to maximal assistance with eating, bathing, and dressing. Physician orders and the nutrition care plan specified a mechanical soft diet, aspiration precautions, and the need for assistance during meals. Despite these requirements, the resident was observed being fed by a privately hired companion aide who was not licensed, not employed by the facility, and not authorized to provide care according to facility policy. Facility policies stated that only Certified Nurse Assistants under the supervision of a Licensed Nurse should provide routine care, including feeding, and that companion aides hired by families were not permitted to give care or feed residents. Multiple staff interviews confirmed that the companion aide regularly fed the resident lunch without supervision or oversight from facility staff. The Director of Nursing was unaware that the companion aide was feeding the resident, and staff indicated that companion aides were not supervised or trained by the facility to provide such care.
Failure to Monitor and Support Resident Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure adequate nutrition and hydration care for one resident with significant medical needs, including diabetes, depression, and hemiplegia following a stroke. The resident experienced a 6.3% unplanned weight loss over one month, and their meal intake was not consistently monitored as required by facility policy. Observations revealed that the resident was not always assisted or encouraged with meals, despite care plan interventions specifying the need for such support. Documentation of food intake was inconsistent and inaccurate, with staff recording 100% intake when the resident had not eaten, and staff were unaware of the resident's recent weight loss or the specific interventions in the care plan. Interviews with staff indicated a lack of awareness regarding the resident's nutritional status and care plan requirements. Certified Nurse Aides did not have specific assignments to assist residents during meals, and there was confusion about reporting and documenting meal intake. The facility's policy required monitoring and reporting of intake below 75% over two days, but this was not consistently followed. The resident was observed to eat minimal amounts during several meals without staff encouragement or assistance, contributing to the identified deficiency.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
During a recertification survey, it was observed that the facility failed to maintain a medication error rate below 5%, with 3 errors out of 35 opportunities (8.57%) involving one resident. The errors included administering crushed forms of Carbidopa-Levodopa-entacapone and Acidophilus Probiotic tablets, both of which were labeled with instructions to swallow whole and not to crush, chew, or break. The resident did not have a physician order permitting medications to be crushed, and the nurse proceeded to crush the medications despite being aware of the label instructions. The nurse stated that the resident always received medications in crushed form due to difficulty swallowing pills, but did not seek an alternative form or clarification from the physician. Additionally, the same resident was administered an inaccurate dose of Metamucil powder. Instead of using a proper measuring tool, the LPN used a regular eating utensil spoon to measure the powder, as the canister's provided scoop was missing. The nurse acknowledged that this method was not accurate, and the RN Unit Manager confirmed that medications should be measured precisely to ensure correct dosing. The resident involved had severe cognitive impairment, was dependent on staff for all activities of daily living, and was on a mechanical diet with thickened liquids.
Expired Medications and Supplies Found in Medication Storage Room
Penalty
Summary
Surveyors found that the facility failed to ensure drugs and biologicals were labeled and stored according to professional standards in the second-floor medication storage room. During observation, multiple expired medications and medical products were found available and ready for use, including omeprazole, blood glucose monitoring strips and control solutions, bisacodyl suppositories, various BD Insyte Autoguard needles, curos needless connectors, Foley stabilization devices, and Kangaroo pump spike sets. The facility's own policy required removal and disposal of discontinued, contaminated, or expired medications, but these items remained accessible in the storage area. Interviews with nursing staff revealed gaps in the process for checking and removing expired medications. One LPN stated they checked only the top shelf and did not inspect the storage bins with drawers where expired items were located. The RN Unit Manager indicated that while LPNs may check their carts and the room, it was the night shift's responsibility to audit the medication room and carts for expired items. Despite these procedures, expired drugs and biologicals were not removed as required, resulting in the deficiency.
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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 Ossining
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar Manor Nursing & Rehabilitation Center | 1.1 mi | ★★★★★ | 2 | 0 |
| Sunshine Children's Home And Rehab Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Briarcliff Manor Center For Rehab And Nursing Care | 3.3 mi | ★★★★★ | 0 | 0 |
| Sky View Rehabilitation & Health Care Center L L C | 4.4 mi | ★★★★★ | 6 | 0 |
| Tolstoy Foundation Rehabilitation And Nrsg Center | 5.6 mi | ★★★★★ | 40 | 2 |
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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.