A list of the most recent deficiencies for Bethany Life. 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 services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-04 | 2023-12-27 | 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 | 2023-11-02 | 2023-11-22 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-08 | 2023-01-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-12-02 | 2023-01-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-02 | 2023-01-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-02 | 2023-01-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-02 | 2023-01-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-02 | 2023-01-02 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-08 | 2022-12-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-08 | 2022-12-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-08 | 2022-12-11 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-10-05 | 2021-11-05 | 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 | 2021-10-05 | 2021-11-03 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-09-30 | 2021-10-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-30 | 2021-10-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-30 | 2021-10-27 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-09-30 | 2021-10-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-30 | 2021-10-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-30 | 2021-10-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-30 | 2021-10-27 | 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 | 2021-10-05 | 2021-10-26 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-10-05 | 2021-10-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-05 | 2021-10-22 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-10-05 | 2021-10-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-05 | 2021-10-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-05 | 2021-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-05 | 2021-10-19 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-10-05 | 2021-10-13 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-10-05 | 2021-10-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-10-05 | 2021-10-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-23 | 2021-08-09 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-07-23 | 2021-08-09 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-12-12 | 2020-01-20 | 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 | 2019-12-12 | 2020-01-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-12-12 | 2020-01-20 | N |
| Respond appropriately to all alleged violations. | Health | 2019-12-12 | 2020-01-20 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-12-12 | 2020-01-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-12-12 | 2020-01-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-12 | 2020-01-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-12 | 2020-01-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-12 | 2020-01-20 | 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 | 2019-12-12 | 2020-01-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-12 | 2020-01-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-12-12 | 2020-01-20 | 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 | 2019-12-18 | 2020-01-10 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-12-18 | 2019-12-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-18 | 2019-12-26 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-12-18 | 2019-12-24 | 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 | 2019-12-18 | 2019-12-23 | N |
