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Inspection visit

Health inspection

Bethany Woods Nursing and Rehabilitation CenterCMS #34514610 citations on this visit
10 citations recorded

Citations

10 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0550GeneralS&S Dpotential for harm

    F550 - Resident Rights

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0554GeneralS&S Dpotential for harm

    F554 - The right to self-administer medications if the interdisciplinary team, as

    Allow residents to self-administer drugs if determined clinically appropriate.

  • 0584GeneralS&S Bno actual harm

    F584 - Safe Environment

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  • 0641GeneralS&S Bno actual harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0644GeneralS&S Dpotential for harm

    F644 - Coordination

    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0658GeneralS&S Bno actual harm

    F658 - Comprehensive Care Plans

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0676GeneralS&S Dpotential for harm

    F676 - Based on the comprehensive assessment of a resident and consistent with

    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  • 0812GeneralS&S Epotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0867GeneralS&S Epotential for harm

    F867 - Program feedback, data systems and monitoring

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

FAQ · About this visit

Common questions about this visit

What happened during the September 1, 2023 survey of Bethany Woods Nursing and Rehabilitation Center?

This was a inspection survey of Bethany Woods Nursing and Rehabilitation Center on September 1, 2023. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Bethany Woods Nursing and Rehabilitation Center on September 1, 2023?

Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.