Deficiency Records for The Grand at Bethany Skilled Nursing and Therapy
Updated as of September 01, 2020
This is not the most recent data for The Grand at Bethany Skilled Nursing and Therapy. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-12-30 | 2020-01-28 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-30 | 2020-01-28 | Y |
| 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 policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-08-12 | 2019-10-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-08-12 | 2019-10-28 | 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 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-12 | 2019-10-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-10 | 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 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-12 | 2019-09-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-08-12 | 2019-09-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-12 | 2019-09-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-12 | 2019-09-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-12 | 2019-09-03 | 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 | 2019-08-12 | 2019-09-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-12 | 2019-09-03 | Y |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2019-08-12 | 2019-09-03 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-08-12 | 2019-09-03 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-08-31 | 2018-10-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-31 | 2018-10-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-08-31 | 2018-10-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-09-05 | 2018-10-07 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-09-05 | 2018-10-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-09-05 | 2018-10-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-05 | 2018-10-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-09-05 | 2018-10-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-09-05 | 2018-10-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-09-05 | 2018-10-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2017-12-21 | 2018-03-21 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2017-12-21 | 2018-03-17 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2017-12-21 | 2018-02-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-21 | 2018-02-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2017-12-21 | 2018-02-17 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-06-15 | 2017-07-18 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-06-15 | 2017-07-18 | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-06-15 | 2017-07-18 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-06-15 | 2017-07-18 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-06-15 | 2017-07-18 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-06-14 | 2017-07-14 | 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 | 2017-06-14 | 2017-07-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-06-14 | 2017-07-14 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2017-06-14 | 2017-07-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-06-14 | 2017-07-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-06-14 | 2017-07-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-06-14 | 2017-07-14 | N |
