Deficiency Records for Bethany Home Society San Joaquin County
Updated as of April 01, 2024
A list of the most recent deficiencies for Bethany Home Society San Joaquin County. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-24 | 2023-11-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-12 | 2023-11-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-04 | 2023-11-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-04 | 2023-11-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-22 | 2023-10-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-04 | 2022-12-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-04 | 2022-12-03 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-11-04 | 2022-12-03 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-11-04 | 2022-12-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-04 | 2022-12-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-04 | 2022-12-03 | N |
| Use approved construction type or materials. | Fire Safety | 2022-11-08 | 2022-11-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-11-08 | 2022-11-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-08 | 2022-11-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-08 | 2022-11-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-08 | 2022-11-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-08 | 2022-11-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-08 | 2022-11-22 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-11-08 | 2022-11-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-08 | 2022-11-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-04 | 2022-11-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-24 | 2022-02-16 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2019-07-02 | 2019-07-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-07-02 | 2019-07-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-02 | 2019-07-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-02 | 2019-07-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-02 | 2019-07-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-02 | 2019-07-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-02 | 2019-07-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-02 | 2019-07-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-05-09 | 2019-06-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-09 | 2019-06-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-09 | 2019-06-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-09 | 2019-06-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-09 | 2019-06-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-09 | 2019-06-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-09 | 2019-06-05 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-03-29 | 2018-04-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-03-29 | 2018-04-16 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2018-03-29 | 2018-04-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-29 | 2018-04-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-03-29 | 2018-04-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-03-29 | 2018-04-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-03-29 | 2018-04-16 | N |
