A list of the most recent deficiencies for Bethany Pointe Health Campus. 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 implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-31 | 2023-11-24 | 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 | 2023-06-14 | 2023-08-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-14 | 2023-08-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-14 | 2023-08-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-06-14 | 2023-08-08 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-06-06 | 2023-06-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-06 | 2023-06-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-17 | 2023-06-12 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-17 | 2022-12-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-03 | 2022-12-03 | Y |
| 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 | 2022-06-29 | 2022-07-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-29 | 2022-07-22 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-07-12 | 2022-07-13 | 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 | 2022-07-12 | 2022-07-13 | 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 | 2022-07-12 | 2022-07-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-07-12 | 2022-07-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-12 | 2022-07-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-12 | 2022-07-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-12 | 2022-07-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-12 | 2022-07-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-05-13 | 2021-07-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-13 | 2021-07-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-13 | 2021-05-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-05-13 | 2021-05-24 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-05-13 | 2021-05-24 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-05-13 | 2021-05-24 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-05-13 | 2021-05-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-05-13 | 2021-05-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-13 | 2021-05-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-13 | 2021-05-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-13 | 2021-05-24 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-05-13 | 2021-05-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-19 | 2021-05-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-04-19 | 2021-05-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-19 | 2021-05-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-19 | 2021-05-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-19 | 2021-05-11 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-04-19 | 2021-05-11 | 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 | 2021-04-19 | 2021-05-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-19 | 2021-05-11 | N |
