Most Recent Deficiencies for BETHEL LUTHERAN HOME

Updated as of January 01, 2020

The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

The tables below are too small to fit on a phone. More information can be seen using a larger device such as a tablet, laptop, or desktop computer.

Deficiency Deficiency Date
Develop Emergency Preparedness policies and procedures. 2019-01-16
Develop a communication plan. 2019-01-16
Develop and maintain an Emergency Preparedness Program (EP). 2018-04-04
Develop Emergency Preparedness policies and procedures. 2018-04-04
Develop a communication plan. 2018-04-04
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. 2019-01-12
Reasonably accommodate the needs and preferences of each resident. 2019-01-12
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. 2019-01-12
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. 2019-01-12
Assure that each resident?s assessment is updated at least once every 3 months. 2019-01-12
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. 2019-01-12
Ensure each resident receives an accurate assessment. 2019-01-12
Ensure a qualified health professional conducts resident assessments. 2019-01-12
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted 2019-01-12
Ensure services provided by the nursing facility meet professional standards of quality. 2019-01-12
Plan the resident's discharge to meet the resident's goals and needs. 2019-01-12
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. 2019-01-12
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. 2019-01-12
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. 2019-01-12
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. 2019-01-12
Ensure each resident?s drug regimen must be free from unnecessary drugs. 2019-01-12
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 ne 2019-01-12
Ensure medication error rates are not 5 percent or greater. 2019-01-12
Ensure that residents are free from significant medication errors. 2019-01-12
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 2019-01-12
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 2019-01-12
Administer the facility in a manner that enables it to use its resources effectively and efficiently. 2019-01-12
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. 2019-01-12
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. 2019-01-12
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. 2019-01-12
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly 2019-01-12
Provide and implement an infection prevention and control program. 2019-01-12
Implement a program that monitors antibiotic use. 2019-01-12
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. 2019-01-12
Make sure that a working call system is available in each resident's bathroom and bathing area. 2019-01-12
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. 2019-01-12
Have enough outside ventilation via a window or mechanical ventilation, or both. 2019-01-12
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. 2019-01-12
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. 2019-01-12
Respond appropriately to all alleged violations. 2019-01-12
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 2019-01-12
Provide appropriate treatment and care according to orders, resident?s preferences and goals. 2019-01-12
Ensure services provided by the nursing facility meet professional standards of quality. 2018-03-08
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. 2018-03-08
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. 2018-03-08
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 2018-03-08
Have a policy regarding use and storage of foods brought to residents by family and other visitors. 2018-03-08
Keep all essential equipment working safely. 2018-03-08
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. 2018-03-08
Have enough backup water supply for essential areas of the nursing home. 2018-03-08
Provide necessary care and services to maintain or improve the highest well being of each resident . 2017-02-14
Store, cook, and serve food in a safe and clean way. 2017-02-14
Dispose of garbage and refuse properly. 2017-02-14
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. 2017-02-14
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 2017-02-14