Deficiency Records for Bethel Lutheran Home

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Updated as of April 01, 2024

A list of the most recent deficiencies for Bethel Lutheran Home. 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?
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 2024-01-18 2024-03-03 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-01-18 2024-03-03 N
Provide and implement an infection prevention and control program. Health 2024-01-18 2024-03-03 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-01-17 2024-03-02 N
Provide and implement an infection prevention and control program. Health 2023-01-26 2023-02-15 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 2023-01-24 2023-02-08 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-01-24 2023-02-08 N
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Health 2021-08-26 2021-09-17 N
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2021-08-26 2021-09-17 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-08-26 2021-09-17 N
Provide enough food/fluids to maintain a resident's health. Health 2021-08-26 2021-09-17 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2021-08-26 2021-09-17 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2021-08-26 2021-09-17 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 2021-08-26 2021-09-17 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 2021-08-26 2021-09-17 N
Provide and implement an infection prevention and control program. Health 2021-08-26 2021-09-17 N
Meet other general requirements that are deficient. Fire Safety 2021-08-24 2021-09-17 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 2021-08-24 2021-09-17 N