A list of the most recent deficiencies for Bethel Nursing Home Company Inc. 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 that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-01 | 2023-12-28 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-08 | 2023-10-02 | 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 | 2023-08-08 | 2023-10-02 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-08-08 | 2023-10-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-08 | 2023-10-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-29 | 2022-01-20 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-07-27 | 2021-09-25 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-07-27 | 2021-09-25 | 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 | 2021-07-27 | 2021-09-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-27 | 2021-09-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-27 | 2021-09-25 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-07-27 | 2021-09-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-27 | 2021-09-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-27 | 2021-09-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-27 | 2021-09-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-27 | 2021-09-24 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-12-04 | 2020-02-03 | 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 | 2019-12-04 | 2020-02-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-04 | 2020-02-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-04 | 2020-02-03 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-12-04 | 2020-02-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-04 | 2020-02-03 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-12-04 | 2020-02-03 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-11-07 | 2020-01-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-07 | 2020-01-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-07 | 2020-01-02 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2019-11-07 | 2020-01-02 | 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 | 2019-11-07 | 2020-01-02 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-11-07 | 2020-01-02 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-04-17 | 2018-06-26 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-04-17 | 2018-06-26 | 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 | 2018-04-17 | 2018-06-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-04-17 | 2018-06-26 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2018-04-17 | 2018-06-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-17 | 2018-06-26 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-04-17 | 2018-06-15 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-04-17 | 2018-06-15 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-04-17 | 2018-06-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-04-17 | 2018-06-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-04-17 | 2018-06-15 | 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 | 2018-04-17 | 2018-06-15 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2018-04-17 | 2018-06-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-04-17 | 2018-06-15 | N |
