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 |