A list of the most recent deficiencies for Bethany Lutheran Home. 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 | 2023-11-02 | 2023-11-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-02 | 2023-11-03 | Y |
| 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 | 2023-08-21 | 2023-09-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-21 | 2023-09-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-21 | 2023-09-14 | Y |
| 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 | 2023-08-21 | 2023-09-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-21 | 2023-09-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-21 | 2023-09-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-21 | 2023-09-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-21 | 2023-09-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-21 | 2023-09-14 | 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 | 2023-08-21 | 2023-09-14 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-21 | 2023-09-14 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-21 | 2023-09-14 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-08-21 | 2023-09-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-21 | 2023-09-14 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-22 | 2023-09-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-22 | 2023-09-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-22 | 2023-09-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-22 | 2023-09-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-08 | 2023-04-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-08 | 2023-04-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-08 | 2023-04-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-08 | 2023-04-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-08 | 2023-04-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-08 | 2023-04-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-08 | 2022-12-21 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-08 | 2022-12-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-08 | 2022-12-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-17 | 2022-12-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-17 | 2022-12-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-17 | 2022-12-21 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-10-17 | 2022-12-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-23 | 2022-07-12 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-06-23 | 2022-07-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-23 | 2022-07-12 | Y |
| 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 | 2022-06-09 | 2022-07-12 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-06-09 | 2022-07-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-09 | 2022-07-12 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-06-09 | 2022-07-12 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-06-09 | 2022-07-12 | Y |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-06-09 | 2022-07-12 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-06-10 | 2022-06-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-06-10 | 2022-06-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-06-10 | 2022-06-20 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2022-06-10 | 2022-06-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-10 | 2022-06-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-19 | 2022-05-09 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-04-19 | 2022-05-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-01 | 2022-03-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-01 | 2022-03-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-01 | 2022-01-13 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-02-18 | 2020-03-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-02-18 | 2020-03-18 | 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 | 2020-02-17 | 2020-03-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-02-17 | 2020-03-17 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-02-17 | 2020-03-17 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2020-02-17 | 2020-03-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-17 | 2020-03-17 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-02-17 | 2020-03-17 | N |
| Assess the resident when there is a significant change in condition | Health | 2020-02-17 | 2020-03-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-17 | 2020-03-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-17 | 2020-03-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-17 | 2020-03-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-17 | 2020-03-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-17 | 2020-03-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-18 | 2020-03-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-18 | 2020-03-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-18 | 2020-03-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-18 | 2020-02-25 | N |
