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 |