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Deficiency Records for New Bethany Skilled Nursing
A list of the most recent deficiencies for New Bethany Skilled Nursing. 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 New Bethany Skilled Nursing. 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? |
|---|---|---|---|---|
| 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 | 2024-10-07 | 2024-11-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-10-07 | 2024-11-02 | Y |
| 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 | 2024-08-28 | 2024-10-08 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2024-08-28 | 2024-10-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-06-21 | 2024-07-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-06-21 | 2024-07-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-21 | 2024-07-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-06-24 | 2024-07-02 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-06-24 | 2024-07-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-06-24 | 2024-07-02 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-06-24 | 2024-07-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-24 | 2024-07-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-06-24 | 2024-07-02 | 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 | 2022-09-23 | 2023-01-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-23 | 2023-01-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-09-23 | 2022-12-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-23 | 2022-12-06 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-09-23 | 2022-12-06 | 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 | 2022-09-23 | 2022-12-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-07 | 2022-10-20 | Y |
| 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 | 2022-09-26 | 2022-10-07 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-02-11 | 2020-03-02 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2020-02-11 | 2020-03-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-11 | 2020-03-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-24 | 2020-02-27 | 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 | 2020-01-24 | 2020-02-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-24 | 2020-02-27 | 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 | 2020-01-24 | 2020-02-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-01-24 | 2020-02-27 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2020-01-24 | 2020-02-27 | 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 | 2020-01-24 | 2020-02-27 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2020-01-24 | 2020-02-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-24 | 2020-02-27 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-01-24 | 2020-02-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-24 | 2020-02-27 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-01-24 | 2020-02-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-24 | 2020-02-27 | N |
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