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Deficiency Records for Bethany at Pacific

View the most recent health deficiencies and inspection results for Bethany at Pacific. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Bethany at Pacific. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Health 2025-06-11 2025-07-18 Y
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. Health 2025-04-21 2025-06-03 N
Allow resident to participate in the development and implementation of his or her person-centered plan of care. Health 2025-04-21 2025-06-03 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 2025-04-21 2025-06-03 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2025-04-21 2025-06-03 N
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 2025-04-21 2025-06-03 N
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2025-04-21 2025-06-03 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2025-04-21 2025-06-03 N
Respond appropriately to all alleged violations. Health 2025-04-21 2025-06-03 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2025-04-21 2025-06-03 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2025-04-21 2025-06-03 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2025-04-21 2025-06-03 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 2025-04-21 2025-06-03 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2025-04-21 2025-06-03 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2025-04-21 2025-06-03 N
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2025-04-21 2025-06-03 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 2025-04-21 2025-06-03 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 2025-04-21 2025-06-03 N
Establish policies and procedures including evacuation. Fire Safety 2025-04-21 2025-05-19 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2025-04-21 2025-05-19 N
Ensure proper usage of power strips and extension cords. Fire Safety 2025-04-21 2025-05-19 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2025-04-21 2025-05-19 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2025-04-21 2025-05-19 N
Conduct testing and exercise requirements. Fire Safety 2025-04-21 2025-05-19 N
Create arrangements with other facilities to receive patients. Fire Safety 2025-04-21 2025-05-19 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2025-04-21 2025-05-19 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
PASARR screening for Mental disorders or Intellectual Disabilities 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
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
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
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
Establish policies and procedures for medical documentation. Fire Safety 2024-06-12 2024-07-02 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-06-12 2024-07-02 N
Address patient/client population and determine types of services needed. Fire Safety 2024-06-12 2024-07-02 N
Address subsistence needs for staff and patients. Fire Safety 2024-06-12 2024-07-02 N
Establish policies and procedures including evacuation. Fire Safety 2024-06-12 2024-07-02 N
Establish policies and procedures for sheltering. Fire Safety 2024-06-12 2024-07-02 N
Establish roles under a Waiver declared by secretary. Fire Safety 2024-06-12 2024-07-02 N
Develop a communication plan. Fire Safety 2024-06-12 2024-07-02 N
Provide primary/alternate means for communication. Fire Safety 2024-06-12 2024-07-02 N
Establish methods for sharing information. Fire Safety 2024-06-12 2024-07-02 N
Provide a means of sharing information on occupancy/needs. Fire Safety 2024-06-12 2024-07-02 N
Conduct testing and exercise requirements. Fire Safety 2024-06-12 2024-07-02 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2024-06-12 2024-07-02 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2024-06-12 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
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
Keep signed and dated reports of x-rays and other diagnostic services in the residents record. 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
Provide appropriate treatment and care according to orders, resident?s preferences and goals. 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 enough food/fluids to maintain a resident's health. 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
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
PASARR screening for Mental disorders or Intellectual Disabilities Health 2023-08-07 2023-09-05 N
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
Ensure proper usage of power strips and extension cords. Fire Safety 2023-08-07 2023-08-17 N
Have proper medical gas storage and administration areas. Fire Safety 2023-08-07 2023-08-17 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-08-07 2023-08-17 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-08-07 2023-08-17 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2023-08-07 2023-08-17 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-08-07 2023-08-17 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-08-07 2023-08-17 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2023-08-07 2023-08-17 N
List the names and contact information of those in the facility. Fire Safety 2023-08-07 2023-08-17 N
Establish methods for sharing information. Fire Safety 2023-08-07 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

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