Deficiency Records for Bethany at Silver Lake
Updated as of February 01, 2021
This is not the most recent data for Bethany at Silver Lake. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2020-04-07 | 2020-04-30 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-10-24 | 2019-12-05 | 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 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-12 | 2019-10-10 | Y |
| 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 |
| Respond appropriately to all alleged violations. | Health | 2019-05-22 | 2019-06-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-23 | 2019-03-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-01-23 | 2019-03-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-01-23 | 2019-03-07 | Y |
| 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 | 2018-12-05 | 2019-01-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-05 | 2019-01-15 | Y |
| Honor the resident's right to choose his or her attending physician. | Health | 2018-10-03 | 2018-11-27 | N |
| Respond appropriately to all alleged violations. | Health | 2018-10-03 | 2018-11-27 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-10-03 | 2018-11-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-03 | 2018-11-27 | 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 | 2018-10-03 | 2018-11-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-03 | 2018-11-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-03 | 2018-11-27 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-10-03 | 2018-11-27 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-10-03 | 2018-11-27 | 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 | 2018-10-03 | 2018-11-27 | N |
| Provide or obtain dental services for each resident. | Health | 2018-10-03 | 2018-11-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-03 | 2018-11-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-03 | 2018-11-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-03 | 2018-11-27 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-03 | 2018-11-27 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-10-03 | 2018-11-27 | Y |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-10-09 | 2018-10-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-18 | 2018-06-07 | Y |
| Provide activities to meet the interests and needs of each resident. | Health | 2017-06-14 | 2017-07-15 | N |
| Provide housekeeping and maintenance services. | Health | 2017-06-14 | 2017-07-15 | N |
| Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. | Health | 2017-06-14 | 2017-07-15 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-06-14 | 2017-07-15 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-06-14 | 2017-07-15 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-06-14 | 2017-07-15 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-06-14 | 2017-07-15 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-06-14 | 2017-07-15 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-06-14 | 2017-07-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-06-08 | 2017-06-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-06-08 | 2017-06-09 | N |
