A list of the most recent deficiencies for Bethesda of Beresford. 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 | 2023-10-04 | 2023-11-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-04 | 2023-11-02 | Y |
| 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 | 2023-04-05 | 2023-05-20 | 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 | 2023-04-05 | 2023-05-20 | 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 | 2023-04-05 | 2023-05-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-05 | 2023-05-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-04 | 2023-05-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-10-07 | 2021-11-04 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-10-07 | 2021-11-04 | 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 | 2021-10-07 | 2021-11-04 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-10-07 | 2021-11-04 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-10-07 | 2021-11-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-07 | 2021-11-04 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-10-07 | 2021-11-04 | 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 | 2021-10-07 | 2021-11-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-07 | 2021-11-04 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-10-05 | 2021-11-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-05 | 2021-10-27 | N |
| Respond appropriately to all alleged violations. | Health | 2020-02-05 | 2020-03-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-05 | 2020-03-23 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-05 | 2020-03-23 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2020-02-04 | 2020-02-06 | N |
