Table of Contents
Bethany Nursing Home & Health Related Facility Inc
Inspection Report, Updated April 2013
PFI: 1255
Regional Office: WRO--Rochester Area Office
This report displays citations for the three most recent Certification Surveys, and citations for Complaint Surveys during the past three years.
Summary
This table summarizes the citations in the details section of this report and compares them against the statewide average.
| Measure | This Facility | Statewide Average |
|---|---|---|
| Standard Health Deficiencies | 28 | 18 |
| Life Safety Code Deficiencies | 5 | 7 |
| Total Deficiencies | 33 | 25 |
| Deficiencies Related to Actual Harm or Immediate Jeopardy | 0 | 1 |
| % of Deficiencies Related to Actual Harm or Immediate Jeopardy | 0% | 4% |
Details of Certification and Complaint Surveys
Key to understanding citations and surveys:
Potential for no more than Minimal Harm
Potential for more than Minimal Harm
Actual Harm
Immediate Jeopardy
Isolated
Pattern
Widespread
- Certification surveys are on-site inspections required every 9-15 months by the federal government.
- Complaint surveys are on-site inspections held as the result of a complaint. They are only shown here if they resulted in a citation.
February 15, 2013 Certification Survey
View Statement of Deficiencies issued for this Inspection Cycle
Standard Health Inspection
| Deficiency | Severity  | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
PROPER LABELING OF DRUGS AND BIOLOGICALS  | | |  | n/a |
| RESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS | | | | n/a |
| ACCOMMODATION OF NEEDS AND PREFERENCES | | | | n/a |
| DEVELOP COMPREHENSIVE CARE PLANS | | | | n/a |
| DIGNITY | | | | n/a |
| SERVICES PROVIDED MEET PROFESSIONAL STANDARDS | | | | n/a |
| RESIDENT RECEIVES NOTICE BEFORE ROOM/ROOMMATE CHANGE | | | | n/a |
Standard Life Safety Code Inspection
| No Deficiencies |
|---|
May 4, 2012 Certification Survey
View Statement of Deficiencies issued for this Inspection Cycle
Standard Health Inspection
| Deficiency | Severity | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
| DENTAL SERVICES IN SKILLED NURSING FACILITIES | | | | June 26, 2012 |
| FACILITY ESTABLISHES INFECTION CONTROL PROGRAM | | | | June 26, 2012 |
| NOT EMPLOY PERSONS GUILTY OF ABUSE | | | | June 26, 2012 |
| RESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS | | | | June 26, 2012 |
| SUFFICIENT NURSING STAFF ON A 24-HOUR BASIS | | | | June 26, 2012 |
| FACILITY RESOLVES RESIDENT GRIEVANCES | | | | June 26, 2012 |
| INFORM RESIDENT OF SERVICES/CHARGES/LEGAL RIGHTS/ETC. | | | | June 26, 2012 |
| PROPER LABELING OF DRUGS AND BIOLOGICALS | | | | June 26, 2012 |
Standard Life Safety Code Inspection
| Deficiency | Severity | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
| CORRIDOR DOORS | | | | June 26, 2012 |
March 28, 2012 Complaint Survey
View Statement of Deficiencies issued for this Inspection Cycle
Standard Health Inspection
| Deficiency | Severity | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
| SERVICES PROVIDED MEET PROFESSIONAL STANDARDS | | | | May 21, 2012 |
April 21, 2011 Certification Survey
View Statement of Deficiencies issued for this Inspection Cycle
Standard Health Inspection
| Deficiency | Severity | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
| FACILITY RESOLVES RESIDENT GRIEVANCES | | | | June 21, 2011 |
| NOT EMPLOY PERSONS GUILTY OF ABUSE | | | | May 21, 2011 |
| RESIDENT MAINTAIN NUTRITIONAL STATUS UNLESS UNAVOIDABLE | | | | June 21, 2011 |
| DEVELOP COMPREHENSIVE CARE PLANS | | | | June 21, 2011 |
| FACILITY ESTABLISHES INFECTION CONTROL PROGRAM | | | | June 21, 2011 |
| FACILITY IS FREE OF ACCIDENT HAZARDS | | | | May 27, 2011 |
| SERVICES BY QUALIFIED PERSONS IN ACCORDANCE WITH CARE PLAN | | | | June 21, 2011 |
| SERVICES PROVIDED MEET PROFESSIONAL STANDARDS | | | | June 21, 2011 |
| CRIMINAL HISTORY RECORD CHECK REQUIRED NOTIFICATION POLICIES & PROCEDURES REQUIRED | | | | May 13, 2011 |
| DEPARTMENT CRIMINAL HISTORY REVIEW AUTHORIZED PERSON(S)/CONFIDENTIALITY OF INFORMATION | | | | May 20, 2011 |
| HOUSEKEEPING AND MAINTENANCE SERVICES | | | | May 27, 2011 |
| SURVEY RESULTS READILY ACCESSIBLE TO RESIDENTS | | | | May 27, 2011 |
Standard Life Safety Code Inspection
| Deficiency | Severity | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
| FURNISHING AND DECORATIONS | | | | June 21, 2011 |
| SPRINKLER SYSTEM MAINTENANCE | | | | May 27, 2011 |
| MEDICAL GAS SYSTEM | | | | June 21, 2011 |
| EMERGENCY LIGHTING | | | | June 21, 2011 |
Note: If the latest survey included in this report is more than 12 months old, the Department of Health may have recently surveyed this nursing home or is currently inspecting this home.
If you have questions about the current quality of service delivery at the nursing home, you should contact the facility and request a copy of the latest survey inspection report. The facility is required to post the report in a public area of the nursing home. If you request the report and the nursing home refuses to provide it, please call the New York State Nursing Home Complaint hotline at 1-888-201-4563.