A list of the most recent deficiencies for Bethel Lutheran 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-01 | 2024-01-21 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-12-01 | 2024-01-21 | 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 | 2023-12-01 | 2024-01-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-01 | 2024-01-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-01 | 2024-01-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-01 | 2024-01-21 | 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 | 2023-12-01 | 2024-01-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-01 | 2024-01-21 | 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 | 2023-12-01 | 2024-01-21 | N |
| Dispose of garbage and refuse properly. | Health | 2023-12-01 | 2024-01-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-01 | 2024-01-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-01 | 2024-01-21 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-12-01 | 2024-01-21 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-12-12 | 2023-12-26 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-12-12 | 2023-12-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-12 | 2023-12-26 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-12-12 | 2023-12-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-12 | 2023-12-26 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-12-12 | 2023-12-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-12 | 2023-12-26 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-12-12 | 2023-12-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-12 | 2023-12-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-12 | 2023-12-26 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-12-12 | 2023-12-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-12 | 2023-12-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-29 | 2022-10-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-29 | 2022-10-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-29 | 2022-10-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-29 | 2022-10-17 | 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 | 2022-09-29 | 2022-10-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-29 | 2022-10-17 | 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 | 2022-09-29 | 2022-10-17 | 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 | 2022-09-29 | 2022-10-17 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-09-29 | 2022-10-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-29 | 2022-10-17 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-09-29 | 2022-10-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-29 | 2022-10-17 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-09-29 | 2022-10-17 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-29 | 2022-10-17 | N |
| 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 | 2022-09-29 | 2022-10-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-29 | 2022-10-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-09-29 | 2022-10-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-29 | 2022-10-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-29 | 2022-10-12 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-09-29 | 2022-10-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-29 | 2022-10-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-09-29 | 2022-10-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-29 | 2022-10-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-09-29 | 2022-10-12 | 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 | 2021-08-02 | 2021-08-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-02 | 2021-08-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-02 | 2021-08-10 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-08-02 | 2021-08-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-07-29 | 2021-08-09 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-07-29 | 2021-08-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-29 | 2021-08-09 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-07-29 | 2021-08-09 | 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 | 2021-07-29 | 2021-08-09 | 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 | 2021-07-29 | 2021-08-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-29 | 2021-08-09 | N |
| Dispose of garbage and refuse properly. | Health | 2021-07-29 | 2021-08-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-29 | 2021-08-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-29 | 2021-08-09 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-07-29 | 2021-08-09 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-29 | 2021-08-09 | N |
