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Deficiency Records for Bethany Home Association
View the most recent health deficiencies and inspection results for Bethany Home Association. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Bethany Home Association. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| 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 | 2025-09-02 | 2025-09-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2025-09-02 | 2025-09-17 | Y |
| 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 | 2025-06-25 | 2025-07-07 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2024-08-14 | 2024-10-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-08-14 | 2024-10-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-08-14 | 2024-10-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-14 | 2024-10-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-08-14 | 2024-10-11 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2024-08-14 | 2024-10-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-08-14 | 2024-10-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-08-14 | 2024-10-11 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-08-14 | 2024-10-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-08-14 | 2024-10-11 | 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 | 2024-08-14 | 2024-10-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-14 | 2024-10-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-14 | 2024-10-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-14 | 2024-10-11 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-08-14 | 2024-10-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-08-14 | 2024-10-11 | 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 | 2024-08-14 | 2024-09-06 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-08-14 | 2024-09-06 | 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 | 2024-08-14 | 2024-09-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-14 | 2024-09-06 | N |
| 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 heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-15 | 2023-05-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-15 | 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 | 2023-03-15 | 2023-05-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-15 | 2023-05-04 | 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 | 2023-03-15 | 2023-05-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-15 | 2023-05-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-15 | 2023-05-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-15 | 2023-05-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-15 | 2023-05-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-15 | 2023-05-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-15 | 2023-05-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-15 | 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 |
| 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 | 2021-08-18 | 2021-11-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-18 | 2021-11-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-18 | 2021-11-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-18 | 2021-11-04 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-08-18 | 2021-11-04 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-08-18 | 2021-11-04 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-08-18 | 2021-11-04 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-08-18 | 2021-11-04 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-08-18 | 2021-11-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-18 | 2021-11-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-18 | 2021-11-04 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-08-18 | 2021-11-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-18 | 2021-11-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-08-18 | 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 | 2021-08-18 | 2021-11-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-18 | 2021-11-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-18 | 2021-11-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-08-18 | 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 | 2021-08-18 | 2021-11-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-08-18 | 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 |