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Bethany Rehabilitation Center

Details

Type of Ownership For profit - Corporation
Participates in Medicare? Yes
Participates in Medicaid? Yes
Certified Beds 170
Continuing Care? No
Resident Council? Yes
Family Council? Yes
Multi-Home Chain? No
Located in a Hospital? No
Special Focus Facility? No

View:    Health Inspections  |  Quality Measures  |  Staffing  |  Fire Inspections

Health Inspections  

Most Recent Inspection: 10/06/2010

Date of last standard health inspection: 10/06/2010
Quality Indicator Survey No
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Health Deficiencies for this nursing home: 1
Average number of Health Deficiencies in CO: 3
Average number of Health Deficiencies in US: 3
Range of Health Deficiencies in CO: 0 - 12
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Develop and implement policies for 1) screening and training employees; and the 2) prevention 01/02/2012 00/00/0000 investigation identification

Inspection, 00/09/2011

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep accurate 00/09/2011 00/00/0000 Few complete and organized clinical records on each re
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems 00/09/2011 00/00/0000 Some and extinguishers.
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) Hire only people with no legal history of abusing 00/09/2011 00/00/0000 neglect or mistreatment of residents. neglecting or mistreating residents; or 2) report
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide necessary care and services to maintain or improve the highest well being of each resident. 00/09/2011 00/00/0000 2 Few
Properly care for residents needing special services 00/09/2011 00/00/0000 colostomy including: injections
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep residents' personal and medical records private and confidential. 00/09/2011 00/00/0000 2 Few

Inspection, 00/06/2010

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide housekeeping and maintenance services. 00/06/2010 00/05/2011 2 Some
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 00/06/2010 01/07/2012 2 Few
Have a program that investigates, controls and keeps infection from spreading. 00/06/2010 01/07/2012 2 Some
Provide housekeeping and maintenance services. 00/06/2010 00/05/2011 2 Some
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 00/06/2010 01/07/2012 2 Few
Have a program that investigates 00/06/2010 01/07/2012 Some controls and keeps infection from spreading.
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep each resident free from physical restraints, unless needed for medical treatment. 00/06/2010 00/05/2011 2 Few
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. 00/06/2010 00/04/2011 2 Few
Keep each resident free from physical restraints 00/06/2010 00/05/2011 Few unless needed for medical treatment.
1) Hire only people with no legal history of abusing 00/06/2010 00/04/2011 neglect or mistreatment of residents. neglecting or mistreating residents; or 2) report
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Store, cook, and serve food in a safe and clean way. 00/06/2010 00/05/2011 2 Many
Store 00/06/2010 00/05/2011 and serve food in a safe and clean way. cook
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
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. 00/06/2010 00/05/2011 2 Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. 00/06/2010 01/07/2012 2 Some
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. 00/06/2010 00/05/2011 2 Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. 00/06/2010 01/07/2012 2 Some
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide activities to meet the interests and needs of each resident. 00/06/2010 00/05/2011 2 Some
Provide medically-related social services to help each resident achieve the highest possible quality of life. 00/06/2010 00/05/2011 2 Few
Ensure services provided by the nursing facility meet professional standards of quality. 00/06/2010 00/05/2011 2 Few
Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. 00/06/2010 01/07/2012 2 Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 00/06/2010 00/05/2011 3 Few
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. 00/06/2010 00/05/2011 2 Few
Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. 00/06/2010 00/05/2011 2 Few
Ensure residents maintain acceptable nutritional status. 00/06/2010 00/05/2011 2 Few
Provide activities to meet the interests and needs of each resident. 00/06/2010 00/05/2011 2 Some
Provide medically-related social services to help each resident achieve the highest possible quality of life. 00/06/2010 00/05/2011 2 Few
Ensure services provided by the nursing facility meet professional standards of quality. 00/06/2010 00/05/2011 2 Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 00/06/2010 00/05/2011 3 Few
Ensure that each resident who enters the nursing home without a catheter is not given a catheter 00/06/2010 00/05/2011 and that incontinent patients receive proper servi unless medically necessary
Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. 00/06/2010 00/05/2011 2 Few
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Conduct initial and periodic assessments of each resident's functional capacity. 00/06/2010 00/05/2011 2 Few
Ensure each resident receives an accurate assessment by a qualified health professional. 00/06/2010 00/05/2011 2 Some
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 00/06/2010 00/05/2011 2 Few
Allow residents the right to participate in the planning or revision of care and treatment. 00/06/2010 00/05/2011 2 Few
Conduct initial and periodic assessments of each resident's functional capacity. 00/06/2010 00/05/2011 2 Few
Ensure each resident receives an accurate assessment by a qualified health professional. 00/06/2010 00/05/2011 2 Some
Develop a complete care plan that meets all the resident's needs 00/06/2010 00/05/2011 Few with timetables and actions that can be measured.
Allow residents the right to participate in the planning or revision of care and treatment. 00/06/2010 00/05/2011 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 00/06/2010 00/05/2011 2 Few
Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. 00/06/2010 00/05/2011 2 Some
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 00/06/2010 00/05/2011 2 Few
Ensure residents have the right to have a choice over activities 00/06/2010 00/05/2011 and health care according to their interests their schedules

Inspection, 00/06/2008

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide housekeeping and maintenance services. 00/06/2008 00/04/2009 2 Some
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 00/06/2008 00/04/2009 2 Few
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Store, cook, and serve food in a safe and clean way. 00/06/2008 00/04/2009 2 Many
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. 00/06/2008 00/04/2009 2 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide activities to meet the interests and needs of each resident. 00/06/2008 00/04/2009 2 Some
Ensure services provided by the nursing facility meet professional standards of quality. 00/06/2008 01/03/2010 2 Few
Provide necessary care and services to maintain or improve the highest well being of each resident. 00/06/2008 00/04/2009 2 Few
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. 00/06/2008 00/04/2009 2 Few
Ensure residents maintain acceptable nutritional status. 00/06/2008 00/04/2009 2 Few
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 00/06/2008 00/04/2009 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give residents a notice of rights, rules, services and charges. 00/06/2008 00/04/2009 2 Some
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. 00/06/2008 00/04/2009 2 Few
Allow residents to self-administer drugs if determined safe. 00/06/2008 00/04/2009 2 Few
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 00/06/2008 00/04/2009 2 Some
Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. 00/06/2008 00/04/2009 2 Few
Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. 00/06/2008 00/04/2009 2 Some

Inspection, 00/01/2005

Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Store, cook, and serve food in a safe and clean way. 00/01/2005 02/02/2005 2 Many
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 00/01/2005 02/02/2005 2 Some
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide necessary care and services to maintain or improve the highest well being of each resident. 00/01/2005 02/02/2005 2 Few
Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. 00/01/2005 02/02/2005 2 Few
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. 00/01/2005 02/02/2005 2 Few
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 00/01/2005 02/02/2005 2 Few

Inspection, 02/08/2004

Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure services provided by the nursing facility meet professional standards of quality. 02/08/2004 01/06/2005 2 Few

Inspection, 00/03/2003

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly 00/03/2003 03/01/2003 Some and develop corrective plans of action.
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 00/03/2003 03/01/2003 4 Some

Inspection, 01/03/2001

Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give the resident's representative the ability to exercise the resident's rights. 01/03/2001 00/08/2002 2 Few

Nursing Home Staffing  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

National Average Average in CO Golden Living Center, Asheville
RN Staff Only1 N/A N/A 5 out of 5 stars
Total Number of Residents 86 73 160
Total, Licensed Nurse Staff Hours
per Resident per Day
16 hours 51 minutes 17 hours 54 minutes 2 hours 1 minute
RN Hours
per Resident per Day
16 hours 3 minutes 17 hours 10 minutes 1 hour 18 minutes
LPN/LVN Hours
per Resident per Day
16 hours 17 minutes 16 hours 58 minutes 43 minutes
CNA Hours
per Resident per Day
17 hours 46 minutes 18 hours 39 minutes 2 hours 15 minutes

1 The star rating a nursing home received for the information it provided about its Registered Nurse (RN) staffing. RNs have between 2 and 6 years of education.

Quality Measures  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

Long-Term Residents

Short-Term Residents

Fire Safety Inspections

Lists the fire safety requirements that the nursing home failed to meet. Fire safety results are not included in the nursing home's Overall Rating.

Most Recent Inspection: 10/27/2010

Automatic Sprinkler Systems in all required areas Yes
Date of last standard fire safety inspection: 10/27/2010
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Fire Safety Deficiencies for this nursing home: 0
Average number of Fire Safety Deficiencies in CO: 0
Average number of Fire Safety Deficiencies in US: 2
Range of Fire Safety Deficiencies in CO: 0 - 0

Inspection, 02/07/2010

Automatic Sprinkler Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Automatic sprinkler systems that have been maintained in working order. 02/07/2010 02/02/2011 2 Some
Electrical Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Properly installed electrical wiring and equipment. 02/07/2010 02/02/2011 2 Some
Emergency Plans and Fire Drills Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Record of quarterly fire drills for each shift under varying conditions. 02/07/2010 02/02/2011 2 Some
Exits and Egress Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Exits that are accessible at all times. 02/07/2010 02/02/2011 2 Some
Illumination and Emergency Power Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Emergency lighting that can last at least 1 1/2 hours. 02/07/2010 02/02/2011 2 Some
Medical Gases and Anesthetizing Areas Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Proper fire barriers, ventilation and signs for the transfilling of oxygen. 02/07/2010 02/02/2011 2 Few
Smoke Compartmentation and Control Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Walls that prevent smoke from passing through and would resist fire for at least one hour. 02/07/2010 02/02/2011 2 Some

Inspection, 02/00/2008

Electrical Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Weekly inspections and monthly testing of generators. 02/00/2008 00/04/2009 2 Few
Properly installed electrical wiring and equipment. 02/00/2008 01/00/2009 2 Few
Hazardous Area Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. 02/00/2008 02/04/2008 2 Few

Inspection, 03/01/2005

Exits and Egress Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Exits that are accessible at all times. 03/01/2005 00/00/0000 2 Few
Hazardous Area Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. 03/01/2005 02/02/2006 2 Few
Illumination and Emergency Power Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Emergency lighting that can last at least 1 1/2 hours. 03/01/2005 02/02/2006 2 Few
Properly located and lighted Exit" signs." 03/01/2005 02/02/2006 2 Few
Medical Gases and Anesthetizing Areas Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Proper fire barriers, ventilation and signs for the transfilling of oxygen. 03/01/2005 02/02/2006 2 Few
Vertical Openings Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. 03/01/2005 02/02/2006 2 Some
 

5301 West First Avenue
Lakewood, CO 80226

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