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Deficiency Records for Bethel Manor
A list of the most recent deficiencies for Bethel Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Bethel Manor. 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? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2024-08-06 | 2024-09-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-08-06 | 2024-09-04 | 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 | 2024-08-06 | 2024-09-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-06 | 2024-09-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-06 | 2024-09-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-06 | 2024-09-04 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-08-06 | 2024-09-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-08-06 | 2024-09-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-06 | 2024-09-04 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-07-26 | 2024-08-25 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-07-26 | 2024-08-25 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-26 | 2024-08-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-26 | 2024-08-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-07-26 | 2024-08-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-26 | 2024-08-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-26 | 2024-08-25 | 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 | 2024-07-26 | 2024-08-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-26 | 2024-08-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-26 | 2024-08-25 | N |
| Post nurse staffing information every day. | Health | 2024-07-26 | 2024-08-25 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-07-26 | 2024-08-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-26 | 2024-08-25 | 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 | 2024-07-26 | 2024-08-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-07-26 | 2024-08-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-26 | 2024-08-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-26 | 2024-08-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-07-26 | 2024-08-25 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Develop a communication plan. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-04 | 2023-06-02 | 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 | 2023-05-04 | 2023-06-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-21 | 2023-05-22 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-04-21 | 2023-05-22 | N |
| Post nurse staffing information every day. | Health | 2023-04-21 | 2023-05-22 | 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 | 2023-04-21 | 2023-05-22 | 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 | 2023-04-21 | 2023-05-22 | 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 | 2023-04-21 | 2023-05-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-08 | 2022-03-28 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-08 | 2022-03-28 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2019-04-08 | 2019-05-03 | N |
| Post nurse staffing information every day. | Health | 2019-04-08 | 2019-05-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-08 | 2019-05-03 | N |
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