Bethel Nursing & Rehabilitation Center

Inspection Report
Report Period: March 2010 to February 2014

PFI: 7278
Regional Office: MARO--New Rochelle Area Office

This report displays citations for Certification Surveys and Complaint Surveys during the reporting period.

Summary

This table summarizes the citations in the details section of this report and compares them against the statewide average.

MeasureThis FacilityStatewide Average
Standard Health Deficiencies2323
Life Safety Code Deficiencies610
Total Deficiencies2933
Deficiencies Related to Actual Harm or Immediate Jeopardy11
% of Deficiencies Related to Actual Harm or Immediate Jeopardy3%4%

Details of Certification and Complaint Surveys

Key to understanding citations and surveys:

  • Potential for no more than Minimal Harm
    Potential for no more than Minimal Harm
  • Potential for more than Minimal Harm
    Potential for more than Minimal Harm
  • Actual Harm
    Actual Harm
  • Immediate Jeopardy
    Immediate Jeopardy
  • Isolated
    Isolated
  • Pattern
    Pattern
  • Widespread
    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.
 

March 29, 2013 Certification Survey

View Statement of Deficiencies issued for this Inspection Cycle

Standard Health Inspection

DeficiencySeverity Learn more about severityResidents Affected Learn more about scopeSubstandard Quality of Care Learn more about substandard quality of careCorrection Date Learn more about correction dates
DEVELOP COMPREHENSIVE CARE PLANS View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careMay 25, 2013
DEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careMay 25, 2013
FACILITY IS FREE OF ACCIDENT HAZARDS View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careMay 25, 2013
PROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careMay 25, 2013
RESIDENT NOT CATHETERIZED UNLESS UNAVOIDABLE View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careMay 25, 2013

Standard Life Safety Code Inspection

DeficiencySeverity Learn more about severityResidents Affected Learn more about scopeSubstandard Quality of Care Learn more about substandard quality of careCorrection Date Learn more about correction dates
ALCOHOL BASED HAND RUBS View details of this deficiencyPotential for more than Minimal HarmPatternNot substandard quality of careMay 25, 2013
EMERGENCY LIGHTING View details of this deficiencyPotential for more than Minimal HarmPatternNot substandard quality of careMay 25, 2013
EXIT ACCESS View details of this deficiencyPotential for more than Minimal HarmPatternNot substandard quality of careMay 25, 2013
AUTOMATIC SPRINKLER SYSTEM View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careMay 25, 2013
STANDARDS OF CONSTRUCTION FOR NEW EXISTING NURSING HOME View details of this deficiencyPotential for no more than Minimal HarmPatternNot substandard quality of careMay 25, 2013

February 21, 2012 Certification Survey

View Statement of Deficiencies issued for this Inspection Cycle

Standard Health Inspection

DeficiencySeverity Learn more about severityResidents Affected Learn more about scopeSubstandard Quality of Care Learn more about substandard quality of careCorrection Date Learn more about correction dates
DEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careMarch 30, 2012
FACILITY IS FREE OF ACCIDENT HAZARDS View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careMarch 30, 2012
FACILITY PROVIDES SUFFICIENT FLUID INTAKE View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careMarch 30, 2012
RESIDENT GIVEN TREATMENT TO IMPROVE/MAINTAIN ADLS View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careMarch 30, 2012
RESIDENTS' CARE SUPERVISED BY A PHYSICIAN View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careMarch 30, 2012

Standard Life Safety Code Inspection

No Deficiencies

November 28, 2011 Complaint Survey

View Statement of Deficiencies issued for this Inspection Cycle

Standard Health Inspection

DeficiencySeverity Learn more about severityResidents Affected Learn more about scopeSubstandard Quality of Care Learn more about substandard quality of careCorrection Date Learn more about correction dates
PROPER LABELING OF DRUGS AND BIOLOGICALS View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careDecember 30, 2011

February 23, 2011 Certification Survey

View Statement of Deficiencies issued for this Inspection Cycle

Standard Health Inspection

DeficiencySeverity Learn more about severityResidents Affected Learn more about scopeSubstandard Quality of Care Learn more about substandard quality of careCorrection Date Learn more about correction dates
RESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS View details of this deficiencyActual HarmIsolatedNot substandard quality of careApril 23, 2011
FACILITY MUST LISTEN/RESPOND TO RESIDENT/FAMILY GROUP View details of this deficiencyPotential for more than Minimal HarmPatternNot substandard quality of careApril 23, 2011
MEDICATION ERROR RATES OF 5% OR MORE View details of this deficiencyPotential for more than Minimal HarmPatternNot substandard quality of careMarch 16, 2011
DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careApril 23, 2011
FACILITY ESTABLISHES INFECTION CONTROL PROGRAM View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careApril 23, 2011
FACILITY PROVIDES DRUGS AND BIOLOGICALS View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careApril 23, 2011
FACILITY RESOLVES RESIDENT GRIEVANCES View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careApril 23, 2011
HOUSEKEEPING AND MAINTENANCE SERVICES View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careApril 23, 2011
RESIDENT DRUG REGIMEN REVIEWED MONTHLY BY PHARMACIST View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careApril 23, 2011
RESIDENT MAINTAIN NUTRITIONAL STATUS UNLESS UNAVOIDABLE View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careApril 23, 2011
SERVICES BY QUALIFIED PERSONS IN ACCORDANCE WITH CARE PLAN View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careApril 23, 2011
SERVICES PROVIDED MEET PROFESSIONAL STANDARDS View details of this deficiencyPotential for more than Minimal HarmIsolatedNot substandard quality of careApril 23, 2011

Standard Life Safety Code Inspection

DeficiencySeverity Learn more about severityResidents Affected Learn more about scopeSubstandard Quality of Care Learn more about substandard quality of careCorrection Date Learn more about correction dates
STAIRWAY ENCLOSURES AND VERTICAL SHAFTS View details of this deficiencyPotential for more than Minimal HarmPatternNot substandard quality of careMay 20, 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.