A list of the most recent deficiencies for Bethany at Silver Lake. 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 a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-31 | 2023-12-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-31 | 2023-12-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-10-31 | 2023-12-14 | N |
| Respond appropriately to all alleged violations. | Health | 2023-10-31 | 2023-12-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-31 | 2023-12-14 | N |
| 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 | 2023-10-31 | 2023-12-14 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-31 | 2023-12-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-31 | 2023-12-14 | 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 | 2023-10-31 | 2023-12-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-31 | 2023-12-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-31 | 2023-12-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-31 | 2023-12-14 | N |
| 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 | 2023-10-31 | 2023-12-14 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-31 | 2023-12-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-31 | 2023-12-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-10-31 | 2023-12-14 | 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 | 2023-10-31 | 2023-12-14 | 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 | 2023-10-31 | 2023-12-14 | N |
| Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. | Health | 2023-10-31 | 2023-12-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-31 | 2023-12-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-31 | 2023-12-14 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Establish methods for sharing information. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-26 | 2023-11-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-06 | 2023-08-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-17 | 2023-05-08 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2022-10-27 | 2022-11-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-26 | 2022-07-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-26 | 2022-07-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-05-26 | 2022-07-11 | N |
| 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 | 2022-05-26 | 2022-07-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-26 | 2022-07-11 | N |
| Respond appropriately to all alleged violations. | Health | 2022-05-26 | 2022-07-11 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-05-26 | 2022-07-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-26 | 2022-07-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-26 | 2022-07-11 | 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 | 2022-05-26 | 2022-07-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-26 | 2022-07-11 | N |
| Provide activities to meet all resident's needs. | Health | 2022-05-26 | 2022-07-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-26 | 2022-07-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-26 | 2022-07-11 | N |
| 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 | 2022-05-26 | 2022-07-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-26 | 2022-07-11 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-05-26 | 2022-07-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-26 | 2022-07-11 | N |
| Post nurse staffing information every day. | Health | 2022-05-26 | 2022-07-11 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-05-26 | 2022-07-11 | 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 | 2022-05-26 | 2022-07-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-26 | 2022-07-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-26 | 2022-07-11 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-05-26 | 2022-07-11 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-26 | 2022-07-11 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-05-26 | 2022-07-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-16 | 2022-06-23 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-05-16 | 2022-06-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-16 | 2022-06-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-16 | 2022-06-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-16 | 2022-06-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-16 | 2022-06-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-12 | 2021-04-08 | Y |
| Report COVID19 data to residents and families. | Health | 2021-03-12 | 2021-04-08 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-08-26 | 2019-10-10 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-08-26 | 2019-10-10 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-08-26 | 2019-10-10 | N |
| Respond appropriately to all alleged violations. | Health | 2019-08-26 | 2019-10-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-26 | 2019-10-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-26 | 2019-10-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-26 | 2019-10-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-26 | 2019-10-10 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-08-26 | 2019-10-10 | N |
| Post nurse staffing information every day. | Health | 2019-08-26 | 2019-10-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-08-26 | 2019-10-10 | 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 | 2019-08-26 | 2019-10-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-26 | 2019-10-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-26 | 2019-10-10 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-08-26 | 2019-10-10 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-08-26 | 2019-10-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-08-22 | 2019-09-26 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-08-22 | 2019-09-26 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-08-22 | 2019-09-26 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-08-22 | 2019-09-26 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-08-22 | 2019-09-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-08-22 | 2019-09-26 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-08-22 | 2019-09-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-08-22 | 2019-09-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-22 | 2019-09-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-08-22 | 2019-09-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-22 | 2019-09-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-22 | 2019-09-26 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-08-22 | 2019-09-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-22 | 2019-09-26 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-08-22 | 2019-09-26 | N |
