A list of the most recent deficiencies for Bethany Home Association. 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? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-31 | 2023-09-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-21 | 2023-06-16 | 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 | 2023-04-05 | 2023-05-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-05 | 2023-05-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-05 | 2023-05-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-05 | 2023-05-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-05 | 2023-05-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-05 | 2023-05-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-05 | 2023-05-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-05 | 2023-05-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-05 | 2023-05-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-05 | 2023-05-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-05 | 2023-05-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-05 | 2023-05-04 | N |
| Post nurse staffing information every day. | Health | 2023-03-15 | 2023-04-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-15 | 2023-04-28 | 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 | 2023-03-15 | 2023-04-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-15 | 2023-04-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-15 | 2023-04-28 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-03-15 | 2023-04-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-20 | 2022-05-24 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-09-29 | 2021-11-04 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-09-29 | 2021-11-04 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-09-29 | 2021-11-04 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-09-29 | 2021-11-04 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-09-29 | 2021-11-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-29 | 2021-11-04 | 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 | 2021-09-29 | 2021-11-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-29 | 2021-11-04 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-09-29 | 2021-11-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-29 | 2021-11-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-09-29 | 2021-11-04 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2021-09-29 | 2021-11-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-29 | 2021-11-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-29 | 2021-11-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-09-29 | 2021-11-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-29 | 2021-11-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-09-29 | 2021-11-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-29 | 2021-11-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-29 | 2021-11-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-07 | 2021-11-03 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-07 | 2021-11-03 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-10-07 | 2021-11-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-09-29 | 2021-09-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-18 | 2021-09-01 | 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 | 2021-08-18 | 2021-09-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-08-18 | 2021-09-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-08-18 | 2021-09-01 | 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 | 2021-08-18 | 2021-09-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-18 | 2021-09-01 | N |
| Use approved construction type or materials. | Fire Safety | 2019-08-14 | 2019-09-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-08-14 | 2019-09-13 | 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 | 2019-08-14 | 2019-09-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-08-14 | 2019-09-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-14 | 2019-09-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-14 | 2019-09-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-13 | 2019-07-18 | 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 | 2019-06-13 | 2019-07-18 | N |
