A list of the most recent deficiencies for Bethany 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-16 | 2023-03-27 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-03-16 | 2023-03-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-07 | 2022-03-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-07 | 2022-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-07 | 2022-03-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-03-07 | 2022-03-31 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-03-07 | 2022-03-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-07 | 2022-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-07 | 2022-03-31 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-09-16 | 2021-10-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-08 | 2021-05-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-08 | 2021-05-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-08 | 2021-05-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-08 | 2021-05-06 | 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 | 2021-04-08 | 2021-05-06 | 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 | 2021-04-08 | 2021-05-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-04-08 | 2021-05-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-08 | 2021-05-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-04-08 | 2021-04-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-08 | 2021-04-30 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-04-08 | 2021-04-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-08 | 2021-04-29 | 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 | 2021-04-08 | 2021-04-28 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-04-08 | 2021-04-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-08 | 2021-04-27 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-04-08 | 2021-04-22 | N |
