BETHANY WOODS NURSING AND REHABILITATION CENTER
Inspection History Overview
Health Violations by Year
2023 10 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Allow residents to self-administer drugs if determined clinically appropriate.
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.
Ensure each resident receives an accurate assessment.
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure services provided by the nursing facility meet professional standards of quality.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
2022 21 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Honor the resident's right to organize and participate in resident/family groups in the facility.
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.
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.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Ensure each resident receives an accurate assessment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate treatment and care according to orders, residentβs preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Ensure each residentβs drug regimen must be free from unnecessary drugs.
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.
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
2020 2 violations
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Provide and implement an infection prevention and control program.
2019 15 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Honor the resident's right to organize and participate in resident/family groups in the facility.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Ensure each resident receives an accurate assessment.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide appropriate treatment and care according to orders, residentβs preferences and goals.
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.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Ensure each residentβs drug regimen must be free from unnecessary drugs.
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.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure services provided by the nursing facility meet professional standards of quality.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
2018 21 violations
Reasonably accommodate the needs and preferences of each resident.
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.
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.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Assess the resident when there is a significant change in condition
Ensure each resident receives an accurate assessment.
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate treatment and care according to orders, residentβs preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe, appropriate pain management for a resident who requires such services.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
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.
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.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
2017 8 violations
Conduct initial and periodic assessments of each resident's functional capacity.
Ensure each resident receives an accurate assessment by a qualified health professional.
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide care by qualified persons according to each resident's written plan of care.
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
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.
Detailed Inspection Reports
No detailed inspection reports available yet. Check back soon as we're processing new reports daily.
Fines and Penalties by Year
2018 1 penalties totaling $41,157
Fire Safety Deficiencies
No description available