Inspection Reports for
Bethany Life

The facility failed to ensure proper documentation reflecting that Resident #1 left the facility unattended and returned with staff. The incident was not documented in the clinical record as required, despite staff training on documentation protocols. The facility decided to transfer the resident to a locked unit following the incident.

The complaint investigation found that Resident #1 did not receive Lasix as ordered when their weight increased by 3 pounds from baseline. The issue was substantiated with documentation of missed medication doses and clinical findings of edema.

The facility failed to administer Lasix as ordered for Resident #1 when their weight increased by 3 pounds from baseline, resulting in missed doses of diuretic medication despite documented weight gains and edema. The Director of Nursing confirmed nurses were expected to follow physician orders as written.

Complaint #2677953-C resulted in a deficiency.

The facility failed to ensure residents were free of significant medication errors, specifically failing to follow physician orders for medication administration for Resident #1, resulting in a deficiency.

The complaint involved allegations that Staff C, CNA, was rough and slammed Resident #1 during peri-care, causing the resident to feel unsafe. The facility investigation confirmed the incident and found that the facility failed to report the incident to the appropriate authorities within the required 2-hour timeframe. Staff C was sent home pending investigation. Resident #1's wife confirmed the resident had hemorrhoids likely causing pain. The resident stated Staff C did not intend harm but he felt unsafe during the care.

The facility failed to treat Resident #1 with dignity and respect, and did not timely report the alleged abuse to the Department of Inspection and Appeals and Licensing within the required 2-hour timeframe. Staff C was found to have been rough during peri-care, causing discomfort to the resident. The facility took corrective actions including sending Staff C home and providing education.

Complaint #2647186-C was substantiated, with findings of mistreatment and failure to report and investigate abuse allegations properly.

The facility failed to treat a resident with respect and dignity, failed to ensure all alleged violations involving mistreatment, neglect, or abuse were reported immediately, and failed to notify the Department of Inspection and Appeals and Licensing within required timeframes. The investigation found staff acted too quickly and carelessly during peri-care, causing discomfort and injury to Resident #1, and the facility did not properly document or report the incident.

Complaints #1647088-C and #1647091-C resulted in a deficiency related to medication errors. The complaint was substantiated as evidenced by the findings of incorrect medication administration and documentation failures.

The facility failed to ensure residents were free of significant medication errors, specifically involving Resident #1 who received incorrect medications. Multiple documentation and administration errors were identified, including incorrect dosing and failure to complete incident reports.

The visit was complaint-related due to medication errors involving Resident #1. The complaint was substantiated as the facility confirmed multiple medication administration errors and adverse effects on the resident.

The facility failed to administer medications per physician orders for Resident #1, resulting in multiple medication errors where lorazepam was given instead of clonazepam. This led to Resident #1 experiencing increased anxiety, insomnia, and other adverse effects. The medication errors were identified, reported, and corrective actions including staff coaching and termination were taken.

The investigation of facility reported incident #128158-I resulted in a deficiency related to abuse and neglect. Incident #129334-I did not result in a deficiency. The substantiation status is that the facility was found not in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities due to the abuse incident.

The facility failed to adequately supervise Resident #1, who had a history of sexually inappropriate behavior, resulting in Resident #2 being found in a compromising sexual situation with Resident #1. The investigation found multiple instances of inappropriate sexual behavior by both residents, insufficient supervision by staff, and failure to keep the residents separated despite known risks.

The visit was complaint-related due to an incident on 4/20/25 where Resident #2 was found lying on top of Resident #1 in a sexual situation. The complaint was substantiated as the facility failed to provide adequate supervision and directives to prevent the incident.

The facility failed to adequately supervise two residents with known sexual behavior issues, resulting in an incident where Resident #2 was found lying on top of Resident #1 with both partially undressed. The facility had limited directives to keep the residents apart and insufficient staffing to provide close supervision, despite known risks. Staff and management acknowledged the failure to provide adequate supervision and directives.

Complaints #121834 and #122060 were substantiated. The complaint involved delayed response to call lights, with Resident #2 reporting wait times over 30 minutes and alarm response reports confirming delays of over 19 minutes.

The facility failed to provide sufficient nursing staff to ensure timely response to resident call lights, specifically failing to answer within 15 minutes for Resident #2. The investigation found that staff response times exceeded 15 minutes, with documented delays up to 19 minutes.

The complaint was substantiated by interviews with Resident #2 and staff, as well as review of the Alarm Response Report showing delayed call light responses. The Administrator confirmed the expectation to answer call lights within 15 minutes per State Rules and Federal Regulations.

The facility staff failed to answer call lights within the expected 15-minute timeframe for 1 of 4 residents reviewed (Resident #2). Interviews and alarm response reports confirmed delays exceeding 15 minutes, with one instance of a 19-minute response time.

Complaint #120334-C was not substantiated. Facility reported incident #120319-I was substantiated.

The facility failed to ensure adequate supervision and use of gait belts during resident transfers, resulting in a resident fall with fractures and injuries. Staff noncompliance with gait belt policy led to termination of an employee.

The complaint investigation found that Staff A did not use a gait belt during a transfer of Resident #6, despite the resident's request and facility policy, leading to a fall and fractures. Staff A admitted to not having a gait belt due to theft and was terminated for policy violation.

The facility failed to ensure adequate supervision and proper use of a gait belt for Resident #6, who fell while being assisted to the bathroom, resulting in fractures to multiple toes and other injuries. Staff A did not use a gait belt despite facility policy and resident request, leading to termination of the staff member.

Complaints #119760-C and #119860-C were substantiated. Facility reported incident #119740-I was substantiated. The Immediate Jeopardy began on March 25, 2024 and was removed on March 28, 2024.

The facility failed to provide adequate supervision to a resident who choked on food, resulting in the resident's death and an Immediate Jeopardy situation. The facility implemented corrective actions including staff education on supervision, audits, and policy updates. Additional deficiencies were found related to nursing staff responsiveness and resident records.

The complaint investigation was triggered by the choking incident and death of Resident #1 on 3/25/2024. The investigation found inadequate supervision during meals and failure to document the incident timely. The facility was informed of Immediate Jeopardy starting 3/25/2024 and removed it by 3/28/2024 after corrective actions.

The facility failed to provide adequate supervision to Resident #1 during meals, resulting in choking and death. The facility also failed to respond timely to call lights for 4 residents and failed to document the incident involving Resident #1 in a timely manner. The facility implemented corrective actions including staff education, audits, and policy reviews.

The visit was complaint-related involving allegations of verbal abuse, inadequate care planning, improper discharge procedures, incomplete skin assessments, fall supervision issues, staffing shortages, medication storage violations, improper food preparation and serving temperatures, and infection control deficiencies related to catheter care.

The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to protect residents from verbal abuse, inadequate care planning for pressure ulcers, incomplete discharge summaries, failure to complete weekly skin assessments, inadequate supervision to prevent falls, insufficient staffing levels, improper storage and maintenance of medications, improper pureed food preparation, serving food at unsafe temperatures, and failure to provide appropriate catheter care.

Complaints #118649-C and #119134-C were substantiated. Facility reported incidents #117737-1 and #119029-1 were substantiated. The complaint investigation revealed verbal abuse by staff to Resident #91, failure to protect residents from abuse, and inadequate investigation and corrective actions by the facility.

The facility was found to have deficiencies related to resident rights, abuse and neglect, comprehensive care planning, quality of care, accident hazards, food and nutrition, infection control, and medication management. Several complaints and incidents were substantiated, including verbal abuse by staff and failure to protect residents from abuse. The facility failed to maintain adequate supervision, documentation, and staff training in multiple areas.

The complaint investigation involved allegations of verbal abuse by Staff N towards Resident #91 on 1/26/24, with delays in removing the staff from resident care. Multiple staff interviews revealed concerns about the handling of the incident. Additional abuse investigations for Residents #17, #103, #112, #219, and #220 showed incomplete investigations lacking witness statements. The facility reported a census of 117 residents.

The facility failed to promptly separate a staff member alleged to have verbally abused a resident and did not thoroughly investigate all abuse allegations. Additionally, the facility failed to provide adequate supervision to prevent accidents, resulting in a fall with injury for Resident #103, and was found to be consistently understaffed, impacting resident care and safety.

Complaint #117113-C was substantiated.

The facility was found not in compliance with 42 CFR Part 483 requirements due to failure to follow a doctor's order for treatment of a Stage 3 pressure ulcer for Resident #3. The order was delayed in initiation and not acknowledged timely by nursing staff.

The visit was complaint-related, investigating failure to follow a doctor's order. The deficiency was substantiated as the facility delayed initiating treatment for Resident #3's pressure ulcer.

The facility failed to initiate a prescribed treatment for Resident #3's Stage 3 pressure ulcer from the order date of 11/22/23 until 11/25/23. The Director of Nursing and Assistant Administrator acknowledged the concern about not following the doctor's orders.

Complaint #116479 was substantiated. Complaint #116491 and Facility Reported Incident #116480-I were not substantiated.

The facility was found not in compliance with regulations related to psychotropic drug use, specifically failure to have a physician review and/or discontinue PRN psychotropic medication within 14 days for one resident. Complaint #116479 was substantiated, while #116491 and incident #116480-I were not substantiated.

The complaint investigation found that Resident #1 received PRN Ativan for more than 14 days without physician review or discontinuation. The Director of Nursing acknowledged awareness of the issue and communication with hospice staff.

The facility failed to have a physician review and/or discontinue an as needed (PRN) psychotropic medication, Ativan, within 14 days of the ordered date for one of three residents reviewed. The Director of Nursing acknowledged the issue and discussed it with hospice staff to prevent recurrence.

The complaint investigation substantiated abuse of Resident 64, with bruising caused by staff holding the resident's arms during care. The facility failed to timely report the suspected abuse and notify authorities. Staff involved were suspended and terminated. Other complaints included failure to provide Medicare Non-coverage notice timely, failure to follow physician orders for catheter changes, and failure to maintain oxygen equipment properly.

The facility was found deficient in multiple areas including failure to provide timely Notice of Medicare Non-coverage, substantiated abuse of a resident resulting in bruising, delayed reporting of suspected abuse, failure to follow physician orders for catheter changes, and failure to properly maintain oxygen concentrator filters, all posing minimal harm or potential for actual harm to residents.

The complaint investigation substantiated abuse of one resident (R64) who was bruised after staff held her arms during care. Staff involved were immediately suspended and subsequently terminated. The facility failed to timely report the alleged abuse to the Administrator. The investigation included interviews, record reviews, and staff interviews.

The facility failed to provide the required Notice of Medicare Non-coverage (NOMNC) at least two days prior to the end of covered services for one resident. The facility also failed to assure freedom from abuse for one resident who was found with bruising after staff held her by the arms during care. Additionally, the facility failed to ensure timely reporting of alleged violations and failed to meet professional standards for services provided, including catheter care and respiratory care.

The investigation included substantiated complaints #98881, #99150, #99151, #99152, and #99176, and a not substantiated complaint #99443.

The facility was found to have multiple deficiencies related to residents' rights, care planning, accident prevention, food procurement, infection control, and discharge procedures. Several complaints and incidents were substantiated, and the facility failed to meet regulatory requirements in several areas including medication changes, care plans, supervision, and infection prevention.

Complaint #97224-C and Complaint #97472-C were substantiated. Multiple Facility Reported Incidents were not substantiated. Mandatory report #97705-M was investigated with results pending.

The facility failed to promptly notify families or representatives of the use of cameras in resident rooms and monitors located in public areas for 2 of 5 residents (Resident #9 and Resident #3). This failure also resulted in a violation of residents' personal privacy and confidentiality rights.

Complaint #97224-C and #97472-C were substantiated. Multiple facility reported incidents were investigated with most not substantiated. Mandatory report #97705-M was investigated with results pending.

The facility failed to promptly notify families or representatives of the use of cameras and monitors in resident rooms and public areas for 2 of 5 residents (Resident #3 and Resident #9). The facility also failed to ensure personal privacy related to the use of electronic monitoring devices. Informed consent was obtained after the fact for Resident #9 and similarly situated residents. The facility implemented policies and staff education to address these issues.

Incident #90389 was substantiated. Resident #1 ingested tea tree oil from another resident's room on the secured dementia unit, causing hypoxia and requiring emergency transfer. Staff failed to report or remove the hazardous item despite awareness.

The facility failed to ensure the resident environment was free from accident hazards, resulting in Resident #1 ingesting tea tree oil and requiring emergency room transfer. Staff were aware of the presence of the oil but failed to report or remove it.