A list of the most recent deficiencies for Beth Haven Nursing 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? |
|---|---|---|---|---|
| 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 | 2023-05-02 | 2023-09-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-02 | 2023-09-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-02 | 2023-09-01 | N |
| Respond appropriately to all alleged violations. | Health | 2023-05-02 | 2023-09-01 | 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 | 2023-05-02 | 2023-09-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-02 | 2023-09-01 | 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 | 2023-05-02 | 2023-09-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-02 | 2023-09-01 | 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 | 2023-05-02 | 2023-09-01 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-05-02 | 2023-09-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-02 | 2023-09-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-02 | 2023-09-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-02 | 2023-09-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-02 | 2023-06-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-02 | 2023-06-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-02 | 2023-06-26 | N |
| 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 | 2023-05-02 | 2023-06-26 | N |
| 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 | 2023-05-02 | 2023-06-26 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-05-02 | 2023-06-26 | N |
| Post nurse staffing information every day. | Health | 2023-05-02 | 2023-06-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-02 | 2023-06-26 | 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 | 2023-05-02 | 2023-06-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-02 | 2023-06-26 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-05-02 | 2023-06-26 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-05-02 | 2023-06-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-02 | 2023-06-26 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2023-05-02 | 2023-06-26 | N |
| Use approved construction type or materials. | Fire Safety | 2023-05-02 | 2023-06-26 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-05-02 | 2023-06-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-02 | 2023-06-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-02 | 2023-06-26 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-11-04 | 2022-12-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-04 | 2022-12-08 | Y |
| 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 | 2022-11-04 | 2022-12-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-04 | 2022-12-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-04 | 2022-12-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-04 | 2022-12-08 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-09-02 | 2022-12-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-02 | 2022-12-08 | Y |
| 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 | 2022-09-02 | 2022-12-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-02 | 2022-12-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-02 | 2022-12-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-02 | 2022-12-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-28 | 2022-07-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-28 | 2022-07-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-28 | 2022-07-27 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-28 | 2022-07-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-30 | 2022-04-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-30 | 2022-04-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-30 | 2022-04-28 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-11-10 | 2022-01-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-10 | 2022-01-28 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-10 | 2022-01-28 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-11-10 | 2022-01-28 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-11-10 | 2022-01-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-12 | 2019-11-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-12 | 2019-11-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-12 | 2019-10-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-12 | 2019-10-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-12 | 2019-10-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-12 | 2019-10-23 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2019-09-12 | 2019-10-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-12 | 2019-10-23 | 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 | 2019-09-12 | 2019-10-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-09-12 | 2019-10-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-12 | 2019-10-23 | 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 | 2019-09-12 | 2019-10-23 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-09-12 | 2019-10-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-09-12 | 2019-10-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-12 | 2019-10-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-12 | 2019-10-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-12 | 2019-10-23 | 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 | 2019-09-12 | 2019-10-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-12 | 2019-10-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-12 | 2019-10-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-12 | 2019-10-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-12 | 2019-10-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-12 | 2019-10-23 | N |
| Meet other general requirements. | Fire Safety | 2019-09-12 | 2019-10-23 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2018-08-16 | 2018-09-28 | N |
| Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. | Health | 2018-08-16 | 2018-09-28 | N |
| 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 | 2018-08-16 | 2018-09-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-08-16 | 2018-09-28 | N |
| Respond appropriately to all alleged violations. | Health | 2018-08-16 | 2018-09-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-16 | 2018-09-28 | N |
| Provide activities to meet all resident's needs. | Health | 2018-08-16 | 2018-09-28 | 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 | 2018-08-16 | 2018-09-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-08-16 | 2018-09-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-16 | 2018-09-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-08-16 | 2018-09-28 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-08-16 | 2018-09-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-08-16 | 2018-09-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-16 | 2018-09-28 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2018-08-16 | 2018-09-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-08-16 | 2018-09-28 | N |
