A list of the most recent deficiencies for Bethel Pointe Health and Rehab. 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? |
|---|---|---|---|---|
| Meet other general requirements. | Fire Safety | 2023-05-23 | 2023-06-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-23 | 2023-06-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-23 | 2023-06-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-09 | 2023-06-02 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-05-09 | 2023-06-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-09 | 2023-06-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-09 | 2023-06-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-09 | 2023-06-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-09 | 2023-06-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-20 | 2023-01-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-25 | 2022-11-16 | Y |
| 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 | 2022-04-25 | 2022-05-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-11 | 2022-05-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-25 | 2022-05-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-25 | 2022-05-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-25 | 2022-05-17 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-04-25 | 2022-05-17 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-04-25 | 2022-05-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-25 | 2022-05-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-25 | 2022-05-17 | 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 | 2022-04-25 | 2022-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-25 | 2022-05-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-12 | 2022-05-13 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-05-12 | 2022-05-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-12 | 2022-05-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-12 | 2022-05-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-12 | 2022-05-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-12 | 2022-05-13 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-05-12 | 2022-05-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-10 | 2022-02-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-23 | 2021-10-08 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-01-27 | 2020-02-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-27 | 2020-02-13 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2020-01-27 | 2020-02-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-11-26 | 2019-12-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-26 | 2019-12-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-26 | 2019-12-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-26 | 2019-12-16 | N |
| 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 | 2019-11-26 | 2019-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-26 | 2019-12-16 | N |
