Bethany Lutheran Homes, Inc.
Survey Date: Wednesday, July 23, 2014
Survey Type: Fire Safety
Deficiency: K0052 (An approved installation, maintenance and testing program for fire alarm systems.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, August 5, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, July 23, 2014
Survey Type: Fire Safety
Deficiency: K0050 (Record of quarterly fire drills for each shift under varying conditions.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, August 7, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Wednesday, July 23, 2014
Survey Type: Fire Safety
Deficiency: K0046 (Emergency lighting that can last at least 1 1/2 hours.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Friday, August 1, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, July 22, 2014
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 4, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, July 22, 2014
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 4, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, July 22, 2014
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 4, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, July 22, 2014
Survey Type: Health
Deficiency: F0332 (Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 4, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, July 22, 2014
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 4, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, July 22, 2014
Survey Type: Health
Deficiency: F0322 (Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumo)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 4, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, July 22, 2014
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 4, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, July 22, 2014
Survey Type: Health
Deficiency: F0514 (Keep accurate, complete and organized clinical records on each resident that meet professional stand)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 4, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, July 22, 2014
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 4, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Tuesday, July 22, 2014
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, September 4, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)
Survey Date: Monday, August 26, 2013
Survey Type: Health
Deficiency: F0223 (Protect each resident from all abuse, physical punishment, and involuntary separation from others.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, September 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)
Survey Date: Monday, August 26, 2013
Survey Type: Health
Deficiency: F0226 (Develop and implement policies for 1) screening and training employees; and the 2) prevention, ident)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, September 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)
Survey Date: Monday, August 26, 2013
Survey Type: Health
Deficiency: F0225 (1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) rep)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Monday, September 30, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a complaint inspection)
Survey Date: Monday, June 17, 2013
Survey Type: Health
Deficiency: F0425 (Provide routine and emergency drugs through a licensed pharmacist and only under the general supervi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Monday, June 17, 2013
Survey Type: Health
Deficiency: F0274 (Review or revise the resident's care plan after any major change in physical or mental health.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Monday, June 17, 2013
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Monday, June 17, 2013
Survey Type: Health
Deficiency: F0176 (Allow residents to self-administer drugs if determined safe.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Monday, June 17, 2013
Survey Type: Health
Deficiency: F0431 (Maintain drug records and properly mark/label drugs and other similar products according to accepted)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Monday, June 17, 2013
Survey Type: Health
Deficiency: F0157 (Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decl)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, July 25, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0272 (Conduct initial and periodic assessments of each resident's functional capacity.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0353 (Have enough nurses to care for every resident in a way that maximizes the resident's well being.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0327 (Give each resident enough fluids to keep them healthy and prevent dehydration.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Fire Safety
Deficiency: K0154 (Back-up procedures in place for a faulty automatic sprinkler system.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, June 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0431 (Maintain drug records and properly mark/label drugs and other similar products according to accepted)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0280 (Allow residents the right to participate in the planning or revision of care and treatment.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0499 (Employ staff that are licensed, certified, or registered in accordance with state laws.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0274 (Review or revise the resident's care plan after any major change in physical or mental health.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0318 (Ensure that residents with limited range of motion receive appropriate treatment and services to inc)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0282 (Provide care by qualified persons according to each resident's written plan of care.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0279 (Develop a complete care plan that meets all the resident's needs, with timetables and actions that c)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0312 (Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0315 (Ensure that each resident who enters the nursing home without a catheter is not given a catheter, un)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0425 (Provide routine and emergency drugs through a licensed pharmacist and only under the general supervi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, June 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0514 (Keep accurate, complete and organized clinical records on each resident that meet professional stand)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0157 (Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decl)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Fire Safety
Deficiency: K0052 (An approved installation, maintenance and testing program for fire alarm systems.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, June 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0253 (Provide housekeeping and maintenance services.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0278 (Ensure each resident receives an accurate assessment by a qualified health professional.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, June 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0241 (Provide care for residents in a way that maintains or improves their dignity and respect in full rec)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0221 (Keep each resident free from physical restraints, unless needed for medical treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Fire Safety
Deficiency: K0155 (An approved back-up procedure for a faulty fire alarm system.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Saturday, June 23, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0309 (Provide necessary care and services to maintain or improve the highest well being of each resident .)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)
Survey Date: Thursday, May 10, 2012
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Sunday, July 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)