Deficiency Records for Bethany Nursing Home and Health Related Facility Inc
Updated as of February 01, 2022
This is not the most recent data for Bethany Nursing Home and Health Related Facility Inc. For the most recent information, click here.
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? |
---|---|---|---|---|
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 |
Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2020-08-20 | 2020-10-19 | Y |
Ensure that residents are free from significant medication errors. | Health | 2020-08-20 | 2020-08-07 | Y |
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 |
Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-08-25 | 2017-10-31 | N |
Make sure that each residents' abilities in activities of daily living do not decline, unless unavoidable. | Health | 2017-08-25 | 2017-10-31 | N |
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-08-25 | 2017-10-31 | N |
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-08-25 | 2017-10-24 | N |
Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-08-25 | 2017-10-24 | N |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-25 | 2017-10-24 | N |
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-08-25 | 2017-10-24 | N |
Store, cook, and serve food in a safe and clean way. | Health | 2017-08-25 | 2017-10-24 | N |
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2017-08-25 | 2017-10-24 | N |
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2017-08-25 | 2017-10-24 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2017-08-25 | 2017-10-24 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-08-25 | 2017-10-24 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2017-08-25 | 2017-10-24 | N |