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Deficiency Records for Bethany Woods Nursing and Rehabilitation Center
A list of the most recent deficiencies for Bethany Woods Nursing and Rehabilitation Center. 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 Bethany Woods Nursing and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-09-26 | 2023-10-17 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-09-26 | 2023-10-17 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-09-01 | 2023-09-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-01 | 2023-09-29 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-09-01 | 2023-09-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-01 | 2023-09-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-01 | 2023-09-29 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-09-01 | 2023-09-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-01 | 2023-09-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-01 | 2023-09-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-01 | 2023-09-29 | Y |
| 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 | 2023-09-01 | 2023-09-29 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-02-03 | 2022-03-03 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-02-03 | 2022-03-03 | 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 | 2022-02-03 | 2022-03-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-03 | 2022-03-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-03 | 2022-03-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-03 | 2022-03-03 | 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 | 2022-02-03 | 2022-03-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-03 | 2022-03-03 | 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 | 2022-02-03 | 2022-03-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-02-03 | 2022-03-03 | 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 | 2022-02-03 | 2022-03-03 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-02-03 | 2022-03-03 | 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 | 2022-02-03 | 2022-03-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-03 | 2022-03-03 | Y |
| 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 | 2022-02-03 | 2022-03-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-03 | 2022-03-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-03 | 2022-03-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-03 | 2022-03-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-03 | 2022-03-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-03 | 2022-03-03 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-02-03 | 2022-03-03 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-03 | 2022-03-03 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-02-03 | 2022-03-03 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2020-01-08 | 2020-01-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-08 | 2020-01-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-11 | 2019-12-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-11 | 2019-12-28 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-12-11 | 2019-12-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-11 | 2019-12-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-11 | 2019-12-28 | 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 | 2019-12-11 | 2019-12-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-11 | 2019-12-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-11 | 2019-12-28 | 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 | 2019-12-11 | 2019-12-28 | 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 | 2019-12-11 | 2019-12-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-12-11 | 2019-12-28 | 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 | 2019-12-11 | 2019-12-28 | N |
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