Health inspection·November 14, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy review facility provided documents, facility policies and procedures, and interviews with staff and residents, it was determined that the facility failed to protect the resident's right to be free from mental abuse and neglect by Employee 3 for one of 21 residents (Resident 34) Findings include: Review of facility policy, Resident Rights-Abuse and Crimes against, revised June 16, 2023, revealed, Residents of [NAME] have a right to be free from abuse, neglect, misappropriation of funds and property, and exploitation as defined below. The abuse, neglect, misappropriation of funds or property, or exploitation of residents by [NAME] associates is strictly prohibited and will result in disciplinary action, up to and including termination of employment. Review of Resident 34's clinical record revealed diagnoses that included difficulty walking (Problems with the joints [such as arthritis], bones [such as deformities], circulation [such as peripheral vascular disease], or even pain can make it difficult to walk properly) and muscle weakness (commonly due to lack of exercise, aging, muscle injury, or pregnancy). Review of Resident 34's care plan revealed a care plan with a focus area of Resident 34 has an ADL (activities of daily living) self-care performance deficit. This care plan has an intervention of: Resident 34 requires maximum assistance by staff for toileting, and Resident 34 requires extensive assistance by 1-2 staff to move between surfaces. Stand lift and 2-staff assist, as needed. Interview with Resident 34 on November 12, 2024, at 9:47 AM, revealed that on November 5, 2024, at 6:00 AM, she rang her call bell to request help going to the bathroom. Employee 3 answered her call bell and, when asked for assistance, responded by refusing to help Resident 34 to the bathroom and telling her to go in her brief. Resident 34 stated that this was humiliating but she did not question Employee 3 because she was afraid. Resident 34 stated that she did not void in her brief and a short time later rang her call bell again, and when Employee 3 entered the room, Resident 34 suggested to Employee 3 that they compromise and Employee 3 assist Resident 34 onto the bedpan. Resident 34 said that Employee 3 agreed to this, helped Resident 34 onto the bedpan, and then Employee 3 sat in the Resident's room next to Resident 34 chewing gum while Resident 34 was on the bedpan. Resident 34 stated that she was unable to void on the bedpan with Employee 3 sitting there and was taken off the bedpan. Resident 34 stated that she later rang the call bell a third time, a different staff member answered, and she was finally taken to the bathroom where she was able to void. Resident 34 stated that later that day she completed a grievance form and turned it in to facility staff. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 9 Event ID: 395386 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395386 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bethany Village Retirement Center 5225 Wilson Lane Mechanicsburg, PA 17055 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)