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Deficiency Records for Bethany at Pacific
A list of the most recent deficiencies for Bethany at Pacific. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Bethany at Pacific. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-06-12 | 2024-07-17 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-06-12 | 2024-07-17 | N |
| 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. | Health | 2024-06-12 | 2024-07-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-06-12 | 2024-07-17 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-06-12 | 2024-07-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-06-12 | 2024-07-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-12 | 2024-07-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-06-12 | 2024-07-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-06-12 | 2024-07-17 | N |
| 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. | Health | 2024-06-12 | 2024-07-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-06-12 | 2024-07-17 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-06-12 | 2024-07-17 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-06-12 | 2024-07-17 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-06-12 | 2024-07-17 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-06-12 | 2024-07-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-12 | 2024-07-17 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-06-06 | 2024-07-02 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-06-06 | 2024-07-02 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-06-06 | 2024-07-02 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2024-06-06 | 2024-07-02 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-06-06 | 2024-07-02 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-06-06 | 2024-07-02 | N |
| Develop a communication plan. | Fire Safety | 2024-06-06 | 2024-07-02 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2024-06-06 | 2024-07-02 | N |
| Establish methods for sharing information. | Fire Safety | 2024-06-06 | 2024-07-02 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2024-06-06 | 2024-07-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-06-06 | 2024-07-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-06 | 2024-07-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-06-06 | 2024-07-02 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-06-06 | 2024-07-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-05-16 | 2024-06-25 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-05-16 | 2024-06-25 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-05-16 | 2024-06-25 | Y |
| 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. | Health | 2024-04-17 | 2024-05-17 | Y |
| 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. | Health | 2024-04-17 | 2024-05-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-17 | 2024-05-17 | Y |
| Keep complete, dated laboratory records in the resident's record. | Health | 2024-04-17 | 2024-05-17 | Y |
| Keep signed and dated reports of x-rays and other diagnostic services in the residents record. | Health | 2024-04-17 | 2024-05-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-04-17 | 2024-05-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-07 | 2023-09-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-08-07 | 2023-09-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-07 | 2023-09-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-07 | 2023-09-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-07 | 2023-09-05 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Establish methods for sharing information. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-02 | 2023-08-17 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-06-13 | 2023-07-07 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-06-13 | 2023-07-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-12 | 2023-01-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-01 | 2022-12-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-18 | 2022-04-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-22 | 2020-02-29 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-01-22 | 2020-02-29 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-01-22 | 2020-02-29 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-01-22 | 2020-02-29 | N |
| 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. | Health | 2020-01-22 | 2020-02-29 | N |
| Respond appropriately to all alleged violations. | Health | 2020-01-22 | 2020-02-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-22 | 2020-02-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-22 | 2020-02-29 | N |
| Provide activities to meet all resident's needs. | Health | 2020-01-22 | 2020-02-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-22 | 2020-02-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-22 | 2020-02-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-22 | 2020-02-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-01-22 | 2020-02-29 | N |
| 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. | Health | 2020-01-22 | 2020-02-29 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-01-22 | 2020-02-29 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2020-01-22 | 2020-02-29 | N |
| 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. | Health | 2020-01-22 | 2020-02-29 | N |
| 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. | Health | 2020-01-22 | 2020-02-29 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2020-01-22 | 2020-02-29 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2020-01-22 | 2020-02-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-22 | 2020-02-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-01-22 | 2020-02-29 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2020-01-22 | 2020-02-29 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2020-01-27 | 2020-02-28 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-01-27 | 2020-02-28 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-01-27 | 2020-02-28 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-01-27 | 2020-02-28 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-01-27 | 2020-02-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-27 | 2020-02-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-01-27 | 2020-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-27 | 2020-02-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-27 | 2020-02-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-01-27 | 2020-02-28 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2020-01-27 | 2020-02-28 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2020-01-27 | 2020-02-28 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2020-01-27 | 2020-02-28 | N |
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