Inspection Report Summary
The most recent inspection on September 22, 2025, identified deficiencies related to previously cited violations that were reported as corrected by August 28, 2025. Earlier inspections showed a pattern of deficiencies involving resident care issues such as verbal abuse, nutrition and weight monitoring, medication administration, infection control, and documentation errors. Complaint investigations substantiated concerns about verbal abuse, inadequate incontinent care, and infection control lapses, while many complaint surveys found no deficiencies. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement in addressing prior deficiencies, though issues related to resident care and infection control have recurred over time.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
34% worse than Connecticut average
Connecticut average: 5.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
95% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Census: 153
Capacity: 161
Deficiencies: 1
Sep 22, 2025
Visit Reason
A desk audit was conducted to review the implementation of the Plan of Correction for a violation letter dated August 7, 2025.
Findings
Violations #1 through #6 were identified as corrected as of August 28, 2025. The Director of Nursing was notified of the corrections on September 22, 2025.
Deficiencies (1)
| Description |
|---|
| Violations #1, #2, #3, #4, #5 and #6 |
Report Facts
Licensed Bed Capacity: 161
Census: 153
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sheila Johnson | Director of Nursing | Notified of correction of violations via telephone |
Inspection Report
Renewal
Census: 148
Capacity: 161
Deficiencies: 0
Jul 22, 2025
Visit Reason
The inspection was conducted as a licensing renewal inspection and included review of complaint investigations #CT#42588 (Aspen) and #121748 (Iguis).
Findings
Violations of the General Statutes of Connecticut and/or regulations were identified at the time of this inspection, as noted in an attached violation letter. Certification files were also reviewed.
Complaint Details
Complaint investigations #CT#42588 (Aspen) and #121748 (Iguis) were reviewed during this inspection.
Report Facts
Licensed Bed Capacity: 161
Census: 148
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erin Healy | Administrator | Personnel contacted during inspection |
| Sheila Johnson | DNS | Personnel contacted during inspection |
Inspection Report
Complaint Investigation
Census: 155
Capacity: 161
Deficiencies: 0
Aug 16, 2024
Visit Reason
A complaint investigation survey was conducted to determine compliance with 42 CFR Part 483 requirements for long term care facilities.
Findings
No deficiencies were cited as a result of this complaint investigation survey.
Complaint Details
Complaint Investigation Survey, ACT Reference Numbers CT#25310 and CT#25941, conducted to assess compliance with federal long term care regulations.
Report Facts
Licensed Bed Capacity: 161
Census: 155
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erin Healy | Administrator | Personnel contacted during the inspection |
| Shelia Johnson | Director of Nursing Services | Personnel contacted during the inspection |
| Carla Larocque | Survey Team Leader, RN, NC | Surveyor and report submitter |
Inspection Report
Renewal
Census: 145
Capacity: 161
Deficiencies: 0
Sep 6, 2023
Visit Reason
The inspection was conducted as a licensure renewal inspection and included a complaint investigation.
Findings
The report indicates that no violations of the General Statutes of Connecticut or regulations were identified at the time of this inspection. Certification file verification was completed.
Complaint Details
Complaint investigation was conducted under complaint numbers 21-216411 and 21-134006.
Report Facts
Licensed Bed/Bassinet Capacity: 161
Census: 145
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erin Healy | Administrator | Personnel contacted during the inspection. |
| Sheila Johnson | DNS | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 161
Deficiencies: 2
Apr 11, 2023
Visit Reason
The inspection visit was conducted as a complaint investigation (#34274) following allegations of verbal abuse at Bethel Health Care Center.
Findings
The investigation found that the facility failed to protect a resident from verbal abuse by a housekeeper, and failed to ensure immediate notification to the Administrator following the incident. The housekeeper was terminated due to poor conduct. The facility policies on resident rights and abuse were reviewed, and plans of correction were outlined.
Complaint Details
Complaint #34274 was substantiated with findings that a housekeeper verbally abused Resident #1 and the facility failed to notify the Administrator immediately. The housekeeper was terminated effective 3/24/23 due to poor conduct.
Deficiencies (2)
| Description |
|---|
| Failure to ensure a resident was protected from verbal abuse by a staff member. |
| Failure to ensure immediate notification to the Administrator following an alleged verbal abuse incident. |
Report Facts
Census: 134
Total Capacity: 161
Complaint Number: 34274
Plan of Correction Submission Deadline: Apr 28, 2023
Termination Date: Mar 24, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Siobhan O'Neill | RN | Signature of FLIS staff who submitted the report |
| Shirley Johnson | DNS | Personnel contacted during inspection |
| Karen Gworek | RN, BSN, Supervising Nurse Consultant | Author of the important notice letter regarding the inspection |
| Erin Healy | Administrator | Facility administrator addressed in the notice and involved in the plan of correction |
| Housekeeper #1 | Staff member involved in verbal abuse incident and terminated | |
| Licensed Practical Nurse #1 | Staff member interviewed regarding the incident | |
| Director of Nursing | DON | Interviewed and identified termination of Housekeeper #1 |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 164
Deficiencies: 3
Aug 2, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint Investigation #32557, focusing on violations of Connecticut State regulations identified during unannounced visits to Bethel Health Care Center.
Findings
The inspection found multiple violations related to failure to notify physicians of weight discrepancies and meal refusals for Resident #1, inadequate documentation of incontinence care, and inconsistent weight monitoring practices. The facility was cited for deficiencies in nutrition monitoring, weight documentation, and incontinent care documentation.
Complaint Details
Complaint Investigation #32557 was substantiated with violations identified related to nutrition and weight monitoring, and incontinent care documentation.
Deficiencies (3)
| Description |
|---|
| Failure to notify physician of baseline admission weight and significant weight discrepancies in a timely manner for Resident #1. |
| Failure to obtain a weight on admission, address weight refusals, and address ongoing poor meal intake in a timely manner for Resident #1. |
| Failure to document that incontinent care was provided for Resident #1. |
Report Facts
Census: 139
Licensed Bed Capacity: 164
Complaint Investigation Number: 32557
Plan of Correction Submission Deadline: Aug 30, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erin Healy | Administrator | Named as facility administrator and recipient of the notice |
| Connie Greene | Supervising Nurse Consultant | Signed the notice letter regarding complaint investigation |
Inspection Report
Renewal
Census: 119
Capacity: 161
Deficiencies: 0
Jul 21, 2021
Visit Reason
The inspection visit was conducted as a licensing inspection for renewal purposes.
Findings
Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection. The facility was found to be in compliance with visitation.
Inspection Report
Renewal
Deficiencies: 7
Jul 21, 2021
Visit Reason
Unannounced visits were made to Bethel Health Care Center which concluded on July 21, 2021 by representatives of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a licensure renewal and a certification inspection.
Findings
The report details multiple violations of Connecticut State Agencies regulations noted during the visits, including deficiencies in medication self-administration assessments, advanced directive consent completion, timely medication administration, specialty mattress settings, employee performance evaluations, dental services, and infection control practices. Plans of correction with completion dates were provided for each violation.
Deficiencies (7)
| Description |
|---|
| Facility failed to complete a self-administration assessment to ensure Resident #92 was safe to self-administer medication. |
| Facility failed to ensure completion of the Advanced Directive Consent form for multiple residents. |
| Facility failed to administer medications in a timely manner, with delays noted in medication passes. |
| Facility failed to ensure a specialty mattress was set correctly for Resident #38. |
| Facility failed to ensure employee performance evaluations were completed annually. |
| Facility failed to provide dental services in a timely manner for Resident #42. |
| Facility failed to clean and disinfect the glucometer according to manufacturer guidelines. |
Report Facts
Date of Completion: Aug 30, 2021
Medication administration delay: 165
Number of residents reviewed for advanced directives: 5
Number of residents reviewed for medication administration: 1
Number of residents reviewed for positioning: 2
Number of residents reviewed for dental services: 2
Number of nurse aides reviewed for performance evaluations: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Birtwistle | Supervising Nurse Consultant | Signed letter regarding violations and plan of correction submission |
| RN #1 | Registered Nurse | Identified incomplete performance evaluations and audit of air mattress settings |
| LPN #1 | Licensed Practical Nurse | Observed glucometer cleaning and medication administration |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding Resident #92 self-administration of eye drops |
| LPN #3 | Licensed Practical Nurse | Performed room search for missing dentures |
| LPN #4 | Licensed Practical Nurse | Observed medication pass delays and interviewed about medication administration |
| DNS | Director of Nursing Services | Interviewed regarding advanced directive consent and medication administration |
| Human Resource Manager | Manager | Interviewed regarding employee performance evaluations |
| Speech Language Pathologist (SLP) #1 | Speech Language Pathologist | Interviewed regarding speech consultation for Resident #42 |
Inspection Report
Renewal
Census: 119
Capacity: 161
Deficiencies: 7
Jul 15, 2021
Visit Reason
The inspection was conducted as an unannounced licensure renewal and certification inspection to assess compliance with state regulations and statutes.
Findings
Violations of Connecticut State Agencies regulations were identified during the inspection, including deficiencies related to medication self-administration, advanced directives, medication administration timeliness, specialty mattress settings, employee performance evaluations, dental services, and infection control. Plans of correction were submitted for each violation with completion dates.
Deficiencies (7)
| Description |
|---|
| Failure to complete a self-administration assessment to ensure Resident #92 was safe to self-administer medication. |
| Failure to ensure completion of the Advanced Directive Consent form for multiple residents. |
| Failure to administer medications in a timely manner, with delays up to 2 hours and 45 minutes for some residents. |
| Failure to ensure a specialty mattress was set correctly for Resident #38. |
| Failure to ensure employee performance evaluations were completed annually for nursing aides. |
| Failure to provide dental services in a timely manner for Resident #42. |
| Failure to clean and disinfect the glucometer according to manufacturer guidelines. |
Report Facts
Licensed Bed Capacity: 161
Census: 119
Inspection Dates: Inspection conducted on 7/15/21, 7/16/21, 7/19/21, 7/20/21, and 7/21/21
Plan of Correction Completion Date: All plans of correction have a completion date of 08/30/2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erin Healy | Administrator | Personnel contacted during inspection |
| Diane Judson | DNS | Personnel contacted during inspection and responsible for plan of correction |
| Judy Birtwistle | Supervising Nurse Consultant | Signed notice letter regarding violations and plan of correction |
Inspection Report
Complaint Investigation
Census: 121
Capacity: 161
Deficiencies: 0
Aug 24, 2020
Visit Reason
A COVID-19 Focused Survey and a Complaint Investigation Survey were conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this survey, indicating compliance with infection prevention and control requirements.
Complaint Details
The visit was complaint-related as indicated by the Complaint Investigation Survey, ACTS Reference Number CT00028303. No deficiencies were found.
Report Facts
Capacity: 161
Census: 121
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 4, 2020
Visit Reason
A Complaint Investigation Survey was conducted at Bethel Health Care Center on August 4, 2020 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities.
Findings
No deficiencies were cited as a result of this survey. The facility was in compliance with the requirements of 42 CFR Part 483, Subpart B, at the time of the investigation survey.
Complaint Details
The survey was conducted as a complaint investigation under ACTS Reference Numbers CT00027181 and CT#28144. No deficiencies were found.
Inspection Report
Routine
Census: 116
Capacity: 161
Deficiencies: 0
Jun 27, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 Focused Survey.
Inspection Report
Abbreviated Survey
Census: 119
Capacity: 161
Deficiencies: 0
Jun 13, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey at Bethel Health Care Center.
Report Facts
Capacity: 161
Census: 119
Inspection Report
Abbreviated Survey
Census: 120
Capacity: 161
Deficiencies: 0
Jun 2, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
No deficiencies were cited as a result of this COVID-19 focused survey conducted at Bethel Health Care Center.
Inspection Report
Routine
Deficiencies: 3
May 20, 2020
Visit Reason
An unannounced visit was made to Bethel Health Care Center on May 20, 2020 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting a COVID-19 focused infection control survey.
Findings
The facility failed to utilize Personal Protective Equipment (PPE) according to policy, including staff not wearing surgical masks while handling clean laundry, a nurse aide wearing a surgical mask underneath an N95 mask incorrectly, and a COVID-19 symptom resolved resident remaining on the COVID-19 positive unit for seven days post symptom resolution despite an available empty room.
Deficiencies (3)
| Description |
|---|
| Laundry attendants folding clean towels without wearing surgical masks as required by facility policy. |
| Nurse aide wearing a surgical mask underneath an N95 mask, not adhering to infection control practices. |
| Resident #1 remained on the COVID-19 positive unit for seven days after symptom resolution despite CDC guidelines and an available empty room. |
Report Facts
Days resident remained on COVID-19 positive unit post symptom resolution: 7
Date of inspection visit: May 20, 2020
Plan of correction submission deadline: Jun 6, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karen Gworek | Supervising Nurse Consultant | Signed the notice letter and provided contact for questions regarding violations. |
| Richard Demio | Administrator | Named as facility administrator in the report. |
| Registered Nurse #1 | Quality Assurance Nurse | Provided surgical masks to laundry staff and interviewed during inspection. |
| Director of Nursing | Interviewed regarding PPE use and resident placement; responsible for infection control compliance. |
Inspection Report
Monitoring
Census: 116
Capacity: 161
Deficiencies: 1
May 20, 2020
Visit Reason
The visit was conducted as a COVID-19 infection control monitoring visit to assess compliance with infection control practices during the pandemic.
Findings
Violations of Connecticut State regulations were identified related to infection control practices, including failure to wear masks properly and failure to transfer a COVID-19 symptomatically resolved resident off the COVID-19 positive unit. A citation was issued and a plan of correction was required.
Deficiencies (1)
| Description |
|---|
| Laundry attendants folding clean towels without wearing surgical masks; a nurse aide wearing a surgical mask under an N95 mask; failure to transfer a COVID-19 symptomatically resolved resident off the COVID-19 positive unit in a timely manner. |
Report Facts
Licensed Beds: 161
Census: 116
Citation Number: Citation #2020-17 issued as a result of this inspection
Plan of Correction Due Date: Plan of correction to be submitted by June 6, 2020
Compliance Date: Compliance date for violations set for June 28, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beatrice Vincent | Director of Nursing Services (DNS) | Personnel contacted during inspection |
| David Ostermeyer | Administrator | Personnel contacted during inspection |
| Diane Judson | Quality Assurance Nurse | Personnel contacted during inspection |
| Karen Gworek | Supervising Nurse Consultant | Author of the violation notice letter |
| Richard Demio | Facility Administrator | Signed plan of correction letter |
| Unnamed Quality Assurance Nurse (RN #1) | Quality Assurance Nurse | Provided surgical masks to staff during surveyor inquiry |
| Unnamed Registered Nurse (RN #1) | Registered Nurse | Interviewed regarding facility policy on PPE use |
| Unnamed Nurse Aide (NA #1) | Nurse Aide | Observed wearing surgical mask under N95 mask and interviewed about mask use |
| Unnamed Director of Nursing (DON) | Director of Nursing | Interviewed regarding PPE use and infection control practices |
Inspection Report
Abbreviated Survey
Census: 116
Capacity: 161
Deficiencies: 3
May 20, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The facility failed to utilize Personal Protective Equipment (PPE) in accordance with policy, failed to ensure a staff member wore an N95 mask properly to optimize effectiveness, and failed to transfer a COVID-19 symptom resolved resident off the COVID-19 positive unit in a timely manner.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to utilize proper use of PPE in accordance with policy, including laundry staff not wearing surgical masks while folding clean towels. | SS=D |
| Staff member wore a surgical mask underneath an N95 mask, not adhering to infection control practices. | SS=D |
| Resident who was symptomatically resolved from COVID-19 remained on the COVID-19 positive unit for seven days post symptom resolution instead of being transferred timely. | SS=D |
Report Facts
Capacity: 161
Census: 116
Days resident remained on COVID-19 positive unit post symptom resolution: 7
Time since symptom resolution before transfer: 3
Time since symptoms first appeared: 10
Audit frequency: 5
Inspection Report
Abbreviated Survey
Census: 101
Capacity: 161
Deficiencies: 0
May 9, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The survey found the facility compliant with no deficiencies cited related to infection prevention and control practices for COVID-19.
Report Facts
Capacity: 161
Census: 101
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 28, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The survey found that the facility was in compliance with infection prevention and control requirements related to COVID-19. No deficiencies were cited as a result of this survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 21, 2020
Visit Reason
An unannounced visit was made to Bethel Health Care Center on April 21, 2020, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an inspection related to COVID-19 infection control.
Findings
The facility failed to ensure the proper use of PPE when providing care to residents with known positive COVID-19 status and residents identified as negative. Staff were observed not removing disposable rain ponchos and isolation gowns when entering or providing care to residents who were not confirmed positive for COVID-19, contrary to facility policy.
Complaint Details
The visit was complaint-related, focusing on infection control practices regarding PPE use with COVID-19 positive and negative residents. The report does not explicitly state substantiation status.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the proper use of PPE when providing care to residents with known positive for COVID-19 and then residents who were identified as negative. |
Report Facts
Date of observation: Apr 20, 2020
Residents on unit: 2
Audit frequency: 5
Date of completion: May 22, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Richard Demio | Facility Administrator | Named in plan of correction letters and correspondence regarding the inspection. |
| Cher Michaud | Supervising Nurse Consultant | Facility Licensing and Investigations Section contact for the inspection. |
| NA #1 | Nurse Aide | Observed exiting a resident room with improper PPE use and interviewed regarding PPE practices. |
| RN #1 | Registered Nurse | Interviewed regarding PPE provision and use during shifts. |
| Director of Nurses | Interviewed regarding unit residents and PPE policy compliance; responsible for plan of correction completion. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Apr 20, 2020
Visit Reason
A COVID-19 Focused Survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including proper infection prevention and control practices to prevent the development and transmission of COVID-19.
Findings
The facility failed to ensure the proper use of PPE when providing care to residents known to be positive for COVID-19 and then to residents identified as negative. Staff were observed wearing a disposable rain poncho over a paper isolation gown continuously throughout their shift without doffing between residents, including those who were COVID-19 negative. The facility policy required extended use of gowns and ponchos for the entire shift, which was not consistent with infection control best practices.
Severity Breakdown
SS=B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure the proper use of PPE when providing care to residents with known positive for COVID-19 and then residents who were notified as negatives. | SS=B |
Report Facts
Completion date for plan of correction: May 22, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cher Michaud | RN Supervising Nurse Consultant | Named in letter regarding dispute of deficiency F880 |
| Richard Demio | Facility Administrator | Signed plan of correction response |
Inspection Report
Complaint Investigation
Census: 127
Capacity: 161
Deficiencies: 0
Sep 17, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to complaint #26158.
Findings
No violations of the General Statutes of Connecticut or regulations were identified at the time of this inspection.
Complaint Details
Complaint investigation #26158 was conducted. No violations were found during the inspection.
Report Facts
Licensed Bed: 161
Census: 127
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Richard Demio | Administrator | Personnel contacted during the inspection. |
| Debora Rossi-Stahl | Director of Nursing (DON) | Personnel contacted during the inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 2
May 8, 2019
Visit Reason
An unannounced visit was made to Bethel Health Care Center on May 8, 2019 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation.
Findings
The facility was found to have violations related to failure to provide incontinent care prior to hospital transfer for one resident and failure to ensure timely administration of IV medications for another resident. The findings were based on documentation reviews and staff interviews.
Complaint Details
Complaint #25351. The investigation was complaint-driven as indicated by the complaint number referenced in the letter and the nature of the findings.
Deficiencies (2)
| Description |
|---|
| Failure to ensure the resident received incontinent care prior to leaving the facility. |
| Failure to ensure a medication was received timely from the pharmacy to ensure timely medication administration. |
Report Facts
Plan of correction submission deadline: May 26, 2019
Resident sample size: 3
Resident sample size: 3
Resident involved in medication deficiency: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Newton | Supervising Nurse Consultant | Signed the letter and is the contact for questions regarding deficiencies. |
| Richard Demio | Administrator | Named as recipient of the letter and involved in the facility's response. |
Inspection Report
Deficiencies: 1
Apr 4, 2019
Visit Reason
The inspection was conducted to evaluate the accuracy of assessments related to resident discharge status, specifically reviewing documentation and coding for Resident #125.
Findings
The facility failed to accurately reflect the discharge status of Resident #125 in the Minimum Data Set (MDS) assessment, as the resident was discharged to the community but the MDS indicated discharge to an acute hospital. The facility acknowledged the error and planned to correct the coding.
Deficiencies (1)
| Description |
|---|
| Failure to accurately reflect a resident's status at the time of discharge in the MDS assessment for Resident #125. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #8 | Interviewed regarding the incorrect MDS coding for Resident #125 discharge status. |
Inspection Report
Annual Inspection
Deficiencies: 12
Apr 4, 2019
Visit Reason
Unannounced visits were made to the facility on April 1, 2, 3, and 4, 2019 by representatives of the Facility Licensing & Investigations Section for the purpose of conducting a certification survey, a licensure inspection and multiple investigations.
Findings
The facility was cited for multiple deficiencies including failure to honor residents' advanced directives, failure to notify of significant changes such as weight loss, failure to report injuries of unknown origin, inadequate discharge planning, failure to provide adequate grooming and showers, failure to implement physician medication orders and monitor psychotropic medications appropriately, improper medication storage, failure to follow up on dental recommendations, failure to maintain dishwasher temperatures, and infection control lapses including improper catheter bag placement and sharps storage.
Severity Breakdown
SS=D: 11
SS=E: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to ensure residents' advanced directives were honored and comprehensive, including timely formulation and documentation. | SS=D |
| Failure to notify Advanced Practice Registered Nurse of significant weight loss and failure to implement interventions. | SS=D |
| Failure to report injuries of unknown origin and failure to investigate thoroughly. | SS=D |
| Failure to implement effective discharge planning including ensuring required adaptive equipment and medications were provided upon discharge. | SS=D |
| Failure to provide adequate grooming and showers for dependent residents. | SS=E |
| Failure to implement physician medication orders for dialysis resident and failure to review allergies prior to medication administration. | SS=D |
| Failure to identify significant weight loss and implement interventions to prevent further weight loss. | SS=D |
| Failure to monitor specific behaviors related to antipsychotic medication use and failure to act timely on pharmacy recommendations. | SS=D |
| Failure to ensure medications were stored properly; medications were left unattended on top of medication carts. | SS=D |
| Failure to follow up on dental recommendations in a timely manner and failure to complete annual oral health evaluation. | SS=D |
| Failure to ensure dishwasher temperatures met required standards for cleaning and sanitizing dishes. | SS=D |
| Failure to implement infection control practices including improper catheter bag placement, failure to maintain transmission-based precautions, and improper sharps storage. | SS=D |
Report Facts
Weight loss percentage: 15.36
Weight loss percentage: 12
Medication doses: 10
Medication dose: 2.5
Medication dose: 20
Dishwasher temperature: 150
Dishwasher temperature: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #6 | Registered Nurse | Named in advanced directive non-compliance and CPR event for Resident #273 |
| LPN #1 | Licensed Practical Nurse | Named in advanced directive non-compliance and CPR event for Resident #273 |
| RN #4 | Registered Nurse | Named in injury of unknown origin non-reporting and medication cart storage |
| DNS | Director of Nursing Services | Named in multiple findings including advanced directives, injury reporting, medication storage, and infection control |
| APRN #1 | Advanced Practice Registered Nurse | Named in advanced directive and weight loss findings |
| Pharmacist #1 | Pharmacist | Named in medication monitoring and pharmacy recommendation findings |
| RN #5 | Registered Nurse | Named in allergy and medication administration error |
| Dietician | Named in weight loss monitoring findings | |
| DFM | Dietary Food Manager | Named in dishwasher temperature monitoring findings |
| Person #1 | Named in discharge and grooming findings | |
| Person #2 | Named in discharge and grooming findings | |
| Person #4 | Named in medication order implementation |
Inspection Report
Complaint Investigation
Census: 157
Capacity: 161
Deficiencies: 6
Apr 1, 2019
Visit Reason
The inspection was conducted due to a complaint investigation involving multiple complaint numbers and for licensing inspection purposes.
Findings
The facility was found to have multiple violations including failure to notify the Advanced Practice Registered Nurse (APRN) of significant weight loss, failure to implement policies for injury of unknown origin, failure to accurately reflect resident discharge status, failure to provide adequate grooming and documentation for residents, failure to ensure medications were appropriately stored and administered, and failure to maintain infection control practices.
Complaint Details
The visit was complaint-driven with complaints #23061, 23876, 23077, 23703, 23084, 25046, and 24515 investigated. The complaints involved issues such as failure to notify APRN of weight loss, injury of unknown origin, medication management, and infection control.
Deficiencies (6)
| Description |
|---|
| Failure to notify APRN of significant weight loss for Resident #273. |
| Failure to implement policies and procedures for injury of unknown origin for Residents #17 and #120. |
| Failure to accurately reflect resident discharge status for Resident #125. |
| Failure to provide adequate grooming and documentation for Residents #55 and #123. |
| Failure to ensure medications were appropriately stored and administered, including failure to monitor behavior related to psychotropic medications. |
| Failure to maintain infection control practices related to catheter care and sharps disposal. |
Report Facts
Licensed Bed Capacity: 161
Census: 157
Complaint Numbers: 7
Weight Loss Percentage: 15.36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cher Michaud | Supervising Nurse Consultant | Signed the inspection report and involved in complaint investigation. |
| Richard DeMio | Administrator | Named in correspondence related to plan of correction and facility administration. |
Inspection Report
Plan of Correction
Deficiencies: 10
Apr 1, 2019
Visit Reason
The document is a Plan of Correction submitted in response to a survey conducted at Bethel Health Care Center on April 1, 2, 3, and 4, 2019 by the Facility Licensing Investigations Section of the Department of Health.
Findings
The survey identified multiple violations related to failure to ensure residents' advanced directives were honored, failure to notify APRN of significant weight loss, failure to implement policies for injury of unknown origin, failure to provide adequate grooming and showering, failure to accurately reflect resident status at discharge, failure to monitor and address behaviors related to antipsychotic medication, failure to implement infection control practices, and failure to follow up on dental recommendations among others.
Deficiencies (10)
| Description |
|---|
| Failure to ensure residents' advanced directives were honored and documented timely. |
| Failure to notify Advanced Practice Registered Nurse (APRN) of significant weight loss. |
| Failure to implement policies and procedures for injury of unknown origin and failure to report timely. |
| Failure to provide adequate grooming and showering to residents. |
| Failure to accurately reflect resident status at discharge and ensure proper discharge planning. |
| Failure to monitor behaviors related to antipsychotic medication and failure to address pharmacy recommendations timely. |
| Failure to ensure medications were appropriately stored and secured. |
| Failure to implement infection control practices regarding catheter care and sharps disposal. |
| Failure to ensure dishwasher temperatures met required standards and proper monitoring. |
| Failure to provide annual oral health evaluation policy and follow dental recommendations timely. |
Report Facts
Dates of survey: 4
Plan of Correction completion date: May 13, 2019
Residents reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Richard DeMio | Administrator | Signed the Plan of Correction letter |
| Cher Michaud | Supervising Nurse Consultant | Recipient of the Plan of Correction letter |
| RN #6 | Registered Nurse | Involved in CPR and Advanced Directive review for Resident #273 |
| LPN #1 | Licensed Practical Nurse | Involved in CPR and code event for Resident #273 |
| LPN #2 | Licensed Practical Nurse | Assisted with CPR for Resident #273 |
| DNS | Director of Nurses | Interviewed and involved in multiple findings and plan of correction responsibilities |
| APRN #1 | Advanced Practice Registered Nurse | Involved in weight loss notification and medication monitoring |
| RN #4 | Registered Nurse | Involved in injury reporting and medication cart findings |
| RN #2 | Registered Nurse | Involved in medication administration and dialysis communication review |
| RN #5 | Registered Nurse | Involved in medication error report |
| Pharmacist #1 | Pharmacist | Involved in pharmacy recommendations and medication monitoring |
| Person #1 | Interviewed regarding Resident #123 discharge | |
| Person #2 | Interviewed regarding Resident #123 discharge and assisted living notification | |
| Director of Rehab | Interviewed regarding equipment needs for Resident #123 | |
| Assistant Director of Nursing Services | Interviewed regarding personal hygiene and facial hair removal | |
| Dietician | Interviewed regarding weight monitoring and nutritional support | |
| Infection Control Nurse | Interviewed regarding infection control practices | |
| Director of Nursing | Interviewed regarding injury reporting and other findings |
Inspection Report
Follow-Up
Census: 130
Capacity: 161
Deficiencies: 0
Apr 26, 2018
Visit Reason
The visit was conducted as a desk audit to review the plan of correction for a violation letter dated 2018-03-06.
Findings
The review found that violations 1a,b,c; 2a,b,c,d; 3a,b,j; 4a,b; 5a; 6a,b,j; 7a; and 8a have been corrected.
Report Facts
Licensed Bed Capacity: 161
Census: 130
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Richard Demio | Administrator | Named as personnel contacted during the inspection on page 3. |
| Debra Rossi-Stahl | Director of Nursing Services (DNS) | Named as personnel contacted during the inspection on page 3. |
| Carla Larocque | Nurse Consultant (NC) | Signed the desk audit report on page 5. |
Inspection Report
Plan of Correction
Deficiencies: 1
Plan of Correction Bethel HC COVID 5 20 20 State POC
Visit Reason
The document is a plan of correction filed by the facility in response to violations related to improper use of PPE and infection control practices during the COVID-19 pandemic.
Findings
The facility failed to ensure proper use of PPE, including wearing N95 masks effectively, and failed to transfer a COVID-resolved resident off the unit timely. The plan outlines corrective actions including resident relocation, staff education, and audits.
Severity Breakdown
F-Tag 880 (B): 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to utilize the proper use of PPE in accordance with policy, including failure to ensure staff adherence to infection control practices and timely transfer of a COVID resolved resident. | F-Tag 880 (B) |
Report Facts
Compliance date: Jun 28, 2020
Audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Richard Demio | Facility Administrator | Signed the plan of correction |
Report
Jul 22, 2025
File
complaint-inspection_2025-07-22.pdf
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Jul 22, 2025
File
health-inspection_2025-07-22.pdf
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Oct 29, 2024
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complaint-inspection_2024-10-29.pdf
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May 10, 2024
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complaint-inspection_2024-05-10.pdf
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Sep 6, 2023
File
health-inspection_2023-09-06.pdf
Report
Apr 11, 2023
File
complaint-inspection_2023-04-11.pdf
Report
Jul 21, 2021
File
health-inspection_2021-07-21.pdf
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