A list of the most recent deficiencies for Bethany Village. 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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-24 | 2023-12-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-24 | 2023-12-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-24 | 2023-12-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-24 | 2023-12-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-10-24 | 2023-12-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-24 | 2023-12-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-24 | 2023-12-23 | 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 | 2023-12-01 | 2023-12-20 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-12-01 | 2023-12-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-01 | 2023-12-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-29 | 2023-10-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-29 | 2023-10-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-20 | 2022-11-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-20 | 2022-11-11 | N |
| 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 | 2022-09-20 | 2022-11-07 | 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 | 2022-09-20 | 2022-11-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-20 | 2022-11-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-20 | 2022-11-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-20 | 2022-11-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-09-20 | 2022-11-07 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2022-09-20 | 2022-11-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-11 | 2022-09-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-11 | 2022-09-13 | N |
| 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. | Health | 2022-08-11 | 2022-09-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-11 | 2022-09-13 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-10-27 | 2021-11-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-27 | 2021-11-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-10-27 | 2021-11-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-27 | 2021-11-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-27 | 2021-11-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-08 | 2021-10-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-08 | 2021-10-28 | N |
| Dispose of garbage and refuse properly. | Health | 2021-10-08 | 2021-10-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-17 | 2021-06-01 | Y |
