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Deficiency Records for Bethel Lutheran Nursing and Rehabilitation Center
A list of the most recent deficiencies for Bethel Lutheran 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 Bethel Lutheran 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 a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-07 | 2024-03-07 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-05 | 2024-01-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-05 | 2024-01-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-12-07 | 2024-01-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-07 | 2024-01-08 | 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 | 2023-12-07 | 2024-01-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-07 | 2024-01-08 | 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 | 2023-12-07 | 2024-01-08 | 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 | 2023-12-07 | 2024-01-08 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-12-07 | 2024-01-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-07 | 2024-01-08 | 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 | 2022-11-17 | 2022-12-27 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-17 | 2022-12-27 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-17 | 2022-12-27 | 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 | 2022-11-17 | 2022-12-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-17 | 2022-12-23 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2022-11-17 | 2022-12-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-17 | 2022-12-23 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-17 | 2022-12-23 | Y |
| 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 | 2022-11-17 | 2022-12-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-17 | 2022-12-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-19 | 2021-09-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-08-19 | 2021-09-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-19 | 2021-09-23 | 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 | 2021-08-19 | 2021-09-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-19 | 2021-09-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-19 | 2021-09-23 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2021-08-19 | 2021-09-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-19 | 2021-09-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-19 | 2021-09-23 | 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 | 2021-08-19 | 2021-09-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-19 | 2021-09-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-08-19 | 2021-09-23 | 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 | 2021-08-19 | 2021-09-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-19 | 2021-09-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-19 | 2021-09-23 | N |
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