A list of the most recent deficiencies for Bethany Nursing and Rehab Center. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-09 | 2023-11-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-09 | 2023-11-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-09 | 2023-11-09 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-10-09 | 2023-11-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-09 | 2023-11-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-09 | 2023-11-09 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-09 | 2023-11-09 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-10-09 | 2023-11-09 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-10-09 | 2023-11-09 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-10-09 | 2023-11-09 | Y |
| 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. | Health | 2023-10-09 | 2023-11-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-09 | 2023-11-09 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-09 | 2023-11-09 | Y |
| Dispose of garbage and refuse properly. | Health | 2023-07-20 | 2023-08-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-20 | 2023-08-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-04 | 2023-06-02 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-12-07 | 2022-12-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-12-07 | 2022-12-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-07 | 2022-12-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-12-07 | 2022-12-30 | 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 | 2022-12-07 | 2022-12-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-07 | 2022-12-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-12-07 | 2022-12-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-07 | 2022-12-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-12-07 | 2022-12-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-07 | 2022-12-30 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2022-12-07 | 2022-12-30 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2022-12-07 | 2022-12-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-07 | 2022-12-30 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-12-07 | 2022-12-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-07 | 2022-12-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-17 | 2022-12-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-17 | 2022-12-22 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-11-17 | 2022-12-17 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-11-17 | 2022-12-17 | N |
| 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. | Health | 2022-11-17 | 2022-12-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-17 | 2022-12-17 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-11-17 | 2022-12-17 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-11-17 | 2022-12-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-17 | 2022-12-17 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-11-17 | 2022-12-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-17 | 2022-12-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-17 | 2022-12-17 | 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 | 2022-11-17 | 2022-12-17 | N |
| 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. | Health | 2022-11-17 | 2022-12-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-17 | 2022-12-17 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-11-17 | 2022-12-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-11-17 | 2022-12-17 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-11-17 | 2022-12-17 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-17 | 2022-12-17 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-17 | 2022-12-17 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-11-17 | 2022-12-17 | N |
| Develop a communication plan. | Fire Safety | 2022-11-17 | 2022-12-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-11-17 | 2022-12-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-28 | 2021-11-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-28 | 2021-10-20 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-09-08 | 2021-10-07 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-09-08 | 2021-10-07 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-09-08 | 2021-10-07 | N |
| 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. | Health | 2021-09-08 | 2021-10-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-08 | 2021-10-07 | N |
| Respond appropriately to all alleged violations. | Health | 2021-09-08 | 2021-10-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-08 | 2021-10-07 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-09-08 | 2021-10-07 | N |
| Provide activities to meet all resident's needs. | Health | 2021-09-08 | 2021-10-07 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-09-08 | 2021-10-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-08 | 2021-10-07 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-09-08 | 2021-10-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-09-08 | 2021-10-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-09-08 | 2021-10-07 | 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 | 2021-09-08 | 2021-10-07 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-09-08 | 2021-10-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-09-08 | 2021-10-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-08 | 2021-10-07 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-09-08 | 2021-10-07 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-09-08 | 2021-10-07 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-09-08 | 2021-10-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-08 | 2021-10-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-08 | 2021-10-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-08 | 2021-10-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-08 | 2021-10-07 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-09-08 | 2021-10-07 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-09-08 | 2021-10-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-28 | 2021-09-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-08-25 | 2020-10-08 | N |
| Provide activities to meet all resident's needs. | Health | 2020-08-25 | 2020-10-08 | N |
| 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. | Health | 2020-08-25 | 2020-10-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-08-25 | 2020-10-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-08-25 | 2020-10-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-09-09 | 2020-09-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2020-09-09 | 2020-09-18 | 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 | 2020-09-09 | 2020-09-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-09-09 | 2020-09-09 | N |
