Deficiency Records for Bethany at Pacific
Updated as of August 01, 2021
This is not the most recent data for Bethany at Pacific. For the most recent information, click here.
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? |
---|---|---|---|---|
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2020-10-09 | 2020-11-12 | Y |
Ensure that residents are free from significant medication errors. | Health | 2020-10-09 | 2020-11-12 | Y |
Provide and implement an infection prevention and control program. | Health | 2020-10-09 | 2020-11-12 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-04-21 | 2020-05-08 | Y |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-02-12 | 2020-03-12 | Y |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-12 | 2020-03-12 | 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 |
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 |
Respond appropriately to all alleged violations. | Health | 2020-01-22 | 2020-02-29 | Y |
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 |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-05 | 2019-08-26 | Y |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-20 | 2019-07-12 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-20 | 2019-07-12 | Y |
Respond appropriately to all alleged violations. | Health | 2019-06-10 | 2019-07-12 | Y |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-06-10 | 2019-07-12 | 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 | 2019-05-31 | 2019-07-12 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-05-31 | 2019-07-12 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-05-31 | 2019-07-12 | Y |
Respond appropriately to all alleged violations. | Health | 2019-05-31 | 2019-07-12 | Y |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-05-31 | 2019-07-12 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-31 | 2019-07-12 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-31 | 2019-07-12 | Y |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-03-06 | 2019-05-17 | N |
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-03-13 | 2019-05-06 | N |
Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-03-13 | 2019-05-06 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-13 | 2019-04-16 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-03-13 | 2019-04-16 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-13 | 2019-04-16 | N |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-03-06 | 2019-04-12 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-06 | 2019-04-12 | N |
Ensure each resident receives an accurate assessment. | Health | 2019-03-06 | 2019-04-12 | N |
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-03-06 | 2019-04-12 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-06 | 2019-04-12 | N |
Provide activities to meet all resident's needs. | Health | 2019-03-06 | 2019-04-12 | 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 | 2019-03-06 | 2019-04-12 | N |
Observe each nurse aide's job performance and give regular training. | Health | 2019-03-06 | 2019-04-12 | 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 | 2019-03-06 | 2019-04-12 | 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 | 2019-03-06 | 2019-04-12 | 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 | 2019-03-06 | 2019-04-12 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-06 | 2019-04-12 | N |
Provide and implement an infection prevention and control program. | Health | 2019-03-06 | 2019-04-12 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-03-06 | 2019-04-12 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-16 | 2019-02-18 | Y |
Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-08-10 | 2018-08-27 | Y |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-11-15 | 2018-01-02 | N |
Meet other general requirements that are deficient. | Fire Safety | 2017-11-15 | 2018-01-02 | N |
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-11-17 | 2017-12-06 | N |
Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2017-11-17 | 2017-12-06 | N |
Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-11-17 | 2017-12-06 | N |
Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-11-17 | 2017-12-06 | N |
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. | Health | 2017-11-17 | 2017-12-06 | N |
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. | Health | 2017-11-17 | 2017-12-06 | N |
Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-11-17 | 2017-12-06 | N |
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-11-17 | 2017-12-06 | N |
Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-11-17 | 2017-12-06 | N |