Below 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 Bethany Center For Rehabilitation And Healing Llc during CMS and state inspections, most recent first.
Staff failed to follow hand hygiene and food handling protocols, including handling food with bare hands and not performing hand hygiene before assisting residents with meals or changing gloves. These lapses were observed among CNAs, an Activity Assistant, and a dietary staff member, and were confirmed by facility leadership as not meeting expected standards.
The facility did not provide or document required education about advance directives for four residents, including those with severe cognitive impairment and complex medical conditions. The absence of documentation was confirmed by the Social Services Assistant.
A review of CNA training records showed that all CNAs employed for a full year did not complete the required 12 hours of annual in-service training, with completed hours ranging from 2.0 to 10.5. Staff Development confirmed the annual requirement and stated that in-service hours were tracked by calendar year rather than by each CNA's hire date, resulting in the deficiency.
A registered nurse left medication unattended and out of sight on an over bed table in a resident's room while entering the bathroom to wash her hands, contrary to facility policy requiring medications to be secured at all times. The DON confirmed that medications should not be left unattended.
The facility did not submit accurate direct care staffing data for three consecutive quarters, with PBJ reports showing excessively low weekend staffing and a one-star staff rating. Staffing records and interviews revealed that staff call-ins, improper coding of CNA hours, and inclusion of agency staff contributed to the inaccuracies.
Staff failed to follow infection control protocols when a nurse did not perform hand hygiene or change gloves between administering eye drops to a resident with severe cognitive impairment, and a CNA did not use required PPE or dispose of a soiled brief properly while caring for a resident with a catheter, PICC line, and pressure ulcer.
Failure to Maintain Sanitary Food Handling and Hand Hygiene Practices
Penalty
Summary
Staff failed to adhere to facility policies and professional standards regarding hand hygiene and food handling during meal service. Multiple staff members, including CNAs and an Activity Assistant, were observed handling food with bare hands and failing to perform hand hygiene before assisting residents with meals. Specific incidents included repositioning food on a plate with bare hands, opening a milk carton by inserting a finger, and spreading jelly on toast while holding it with bare hands. Additionally, a CNA was observed feeding a resident after repositioning them in bed and adjusting their pillow, without performing hand hygiene in between tasks. In the kitchen, a dietary staff member was observed preparing meal trays while wearing gloves, but left the serving line multiple times to open equipment and returned to food preparation without changing gloves or performing hand hygiene. This staff member also changed gloves multiple times without performing hand hygiene before donning new gloves. Facility policies required handwashing before starting work in the kitchen, after unsanitary tasks, and before applying gloves, but these procedures were not followed as observed. Interviews with the DON and CDM confirmed that these practices were not in accordance with facility expectations.
Failure to Provide Advance Directive Information and Documentation
Penalty
Summary
The facility failed to provide information and documentation regarding residents' rights to formulate an advance directive for four out of thirty-three sampled residents. According to the facility's policy, the social services director or designee is required to inquire about the existence of any written advance directives and provide written information about the right to accept or refuse medical or surgical treatment and to formulate an advance directive prior to or upon admission. However, for the identified residents, the facility was unable to produce completed documentation showing that either the residents or their representatives were educated about advance directives. The affected residents included individuals with diagnoses such as Alzheimer's Disease, Anxiety, Depression, Diverticulosis, Chronic Obstructive Pulmonary Disease, Bipolar Disorder, Hypertension, Cerebral Infarction, Diabetes, Parkinson's Disease, Left Femur Fracture, Osteoporosis, and Dementia. Some of these residents were severely cognitively impaired, as indicated by low BIMS scores or incomplete assessments, necessitating that their representatives be informed. Despite this, there was no evidence that the required education or documentation was provided. The Social Services Assistant confirmed the absence of advance directive documentation for these residents during an interview.
Failure to Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) employed for a full year received at least 12 hours of in-service training, as required by facility policy. A review of the in-service training records for 23 CNAs revealed that none had completed the mandated 12 hours of annual in-service education. The hours completed by individual CNAs ranged from as low as 2.0 to a maximum of 10.5 hours within the specified timeframes, falling short of the policy requirement. The facility's policy, dated August 2022, clearly states that all personnel are required to participate in regular in-service education, with a minimum of 12 hours per year to ensure continuing competence. During an interview, the Staff Development personnel confirmed the annual requirement of 12 in-service hours for CNAs and acknowledged that no hours had been completed for the current year at the time of the interview. The Staff Development also explained their practice of conducting in-service training over a calendar year, rather than from each CNA's hire date. This approach contributed to the deficiency, as it did not ensure that each CNA received the required training within their individual annual employment periods.
Medication Left Unattended by RN
Penalty
Summary
A deficiency occurred when a registered nurse (RN) left medication unattended and out of sight on an over bed table in a resident's room. The RN entered the bathroom with the door nearly closed to wash her hands, leaving the medication accessible and unsupervised. This action was observed by surveyors and was not in accordance with the facility's policy, which requires that medication carts or trays used to transport medications are not left unattended if open or otherwise potentially available to others. The Director of Nursing confirmed during an interview that medications should not be left unattended and out of sight.
Failure to Accurately Report Direct Care Staffing Data
Penalty
Summary
The facility failed to submit accurate direct care staffing data to CMS for Quarter 2, Quarter 3, and Quarter 4 of 2024, as required. Review of the Payroll Based Journal (PBJ) Staffing Data Reports for these quarters revealed excessively low weekend staffing and a one-star staff rating for Quarter 3. Further examination of direct care staffing records, including facility census and per patient day (PPD) calculations, showed that on five randomly selected Saturdays, the facility reported PPD values greater than 2.7, which were still considered excessively low for weekend staffing during the reviewed quarters. Interviews with the Staffing Director and Administrator confirmed awareness of low weekend staffing, attributed to staff call-ins, and indicated that agency staff were included in the reported numbers. The Administrator also acknowledged that direct care hours for a Certified Nursing Assistant who worked in multiple roles were not properly coded, contributing to inaccuracies in the PBJ submissions. No specific residents or patient conditions were mentioned in relation to the deficiency.
Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper infection control practices were followed during care activities involving two residents. In one instance, a registered nurse administered eye drops to both eyes of a resident with severe cognitive impairment without changing gloves or performing hand hygiene between each eye, contrary to facility policy which requires hand hygiene before treating each eye. This lapse was observed during medication administration and confirmed by the Director of Nursing, who stated that gloves should be changed and hand hygiene performed between eyes. In another instance, a certified nursing assistant did not follow Enhanced Barrier Precautions (EBPs) while providing care to a resident with multiple risk factors for infection, including an indwelling catheter, a PICC line, a stage 3 pressure ulcer, and a history of antibiotic use. The CNA was observed in the resident's room without wearing a gown, despite signage indicating EBPs were required. Additionally, a soiled brief was left unbagged on the floor, and privacy measures were not maintained. Both the LPN and DON confirmed that proper PPE, including gown and gloves, should have been used and that soiled items should not be left on the floor.
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What surveyors actually found near you
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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 Nashville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Antioch Tn Opco, Llc | 3.9 mi | ★★★★★ | 3 | 3 |
| Somerfield At The Heritage | 5.2 mi | ★★★★★ | 0 | 0 |
| Woodcrest At Blakeford | 6.5 mi | ★★★★★ | 10 | 0 |
| Trevecca Center For Rehabilitation And Healing Llc | 6.7 mi | ★★★★★ | 0 | 0 |
| Nashville Center For Rehabilitation And Healing Ll | 6.8 mi | ★★★★★ | 0 | 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.