A list of the most recent deficiencies for Bethel Manor. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Develop a communication plan. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-04 | 2023-06-02 | 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 | 2023-05-04 | 2023-06-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-21 | 2023-05-22 | 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 | 2023-04-21 | 2023-05-22 | N |
| Post nurse staffing information every day. | Health | 2023-04-21 | 2023-05-22 | 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 | 2023-04-21 | 2023-05-22 | 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 | 2023-04-21 | 2023-05-22 | 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 | 2023-04-21 | 2023-05-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-08 | 2022-03-28 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-08 | 2022-03-28 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2019-04-08 | 2019-05-03 | N |
| Post nurse staffing information every day. | Health | 2019-04-08 | 2019-05-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-08 | 2019-05-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-03-20 | 2018-04-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-20 | 2018-04-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-03-20 | 2018-04-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-03-20 | 2018-04-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-03-20 | 2018-04-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-03-20 | 2018-04-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-02-22 | 2018-03-24 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-02-22 | 2018-03-24 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-02-22 | 2018-03-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-02-22 | 2018-03-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-02-22 | 2018-03-24 | 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 | 2018-02-22 | 2018-03-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-02-22 | 2018-03-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-22 | 2018-03-24 | N |
