Deficiency Records for The Grand at Bethany Skilled Nursing and Therapy
Updated as of March 01, 2024
A list of the most recent deficiencies for The Grand at Bethany Skilled Nursing and Therapy. 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? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-28 | 2023-12-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-28 | 2023-12-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-28 | 2023-12-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-28 | 2023-12-27 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-07-27 | 2023-09-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-27 | 2023-09-14 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-07-27 | 2023-09-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-27 | 2023-09-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-11 | 2023-06-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-11 | 2023-06-21 | Y |
| 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 | 2022-04-13 | 2022-05-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-13 | 2022-05-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-04-13 | 2022-05-11 | 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 | 2022-04-13 | 2022-05-11 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-04-13 | 2022-05-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-13 | 2022-05-11 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-04-13 | 2022-05-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-13 | 2022-05-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-13 | 2022-05-11 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-01-25 | 2022-03-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-23 | 2021-11-03 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-09-23 | 2021-11-03 | Y |
| 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 | 2021-09-23 | 2021-11-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-23 | 2021-11-03 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-23 | 2021-11-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-23 | 2021-11-03 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-09-23 | 2021-11-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-23 | 2021-11-03 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-09-23 | 2021-11-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-23 | 2021-11-03 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-09-23 | 2021-11-03 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-10 | 2019-10-28 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-10 | 2019-10-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-10 | 2019-10-28 | 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 | 2019-10-10 | 2019-10-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-09 | 2019-10-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-09 | 2019-10-28 | 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 | 2019-10-09 | 2019-10-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-09 | 2019-10-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-10 | 2019-10-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-10 | 2019-10-21 | N |
