Deficiency Records for Bethany Nursing Home and Health Related Facility Inc
Updated as of April 01, 2024
A list of the most recent deficiencies for Bethany Nursing Home and Health Related Facility 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-24 | 2023-05-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-24 | 2023-05-23 | Y |
| 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 | 2023-03-24 | 2023-05-23 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-03-24 | 2023-05-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-24 | 2023-05-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-24 | 2023-05-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-24 | 2023-05-23 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-03-24 | 2023-05-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-24 | 2023-05-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-24 | 2023-05-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-24 | 2023-05-23 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-03-24 | 2023-05-23 | 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 | 2021-07-23 | 2021-09-21 | 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 | 2021-07-23 | 2021-09-21 | 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 | 2021-07-23 | 2021-09-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-23 | 2021-09-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-23 | 2021-09-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-23 | 2021-09-21 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-07-23 | 2021-09-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-18 | 2019-03-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-01-18 | 2019-03-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-01-18 | 2019-03-18 | 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 | 2019-01-18 | 2019-03-18 | 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 | 2019-01-18 | 2019-03-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-18 | 2019-03-18 | 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 | 2019-01-18 | 2019-03-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-01-18 | 2019-02-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-18 | 2019-02-04 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-01-18 | 2019-01-28 | N |
