Deficiency Records for Bethel Lutheran Home
Updated as of November 01, 2022
This is not the most recent data for Bethel Lutheran Home. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-02-28 | 2019-04-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-02-28 | 2019-04-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-28 | 2019-04-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-28 | 2019-04-19 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-02-28 | 2019-04-19 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-02-26 | 2019-04-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-02-26 | 2019-04-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-02-26 | 2019-04-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-01-18 | 2018-03-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-01-18 | 2018-03-01 | N |
