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Deficiency Records for Pavilion On Pico Healthcare and Wellness Centre, LP
A list of the most recent deficiencies for Pavilion On Pico Healthcare and Wellness Centre, LP. 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 Pavilion On Pico Healthcare and Wellness Centre, LP. 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-11-18 | 2024-12-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-11-18 | 2024-12-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-11-18 | 2024-12-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-11-18 | 2024-12-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-11-17 | 2024-12-03 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-11-17 | 2024-12-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-11-17 | 2024-12-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-11-17 | 2024-12-03 | 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 | 2024-11-17 | 2024-12-03 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-11-17 | 2024-12-03 | 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 | 2024-11-17 | 2024-12-03 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-11-17 | 2024-12-03 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-11-17 | 2024-12-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-11-17 | 2024-12-03 | N |
| Dispose of garbage and refuse properly. | Health | 2024-11-17 | 2024-12-03 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2024-11-17 | 2024-12-03 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-11-17 | 2024-12-03 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-11-17 | 2024-12-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-09 | 2024-08-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-30 | 2024-02-16 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-01 | 2023-11-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-01 | 2023-11-22 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-11-01 | 2023-11-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-01 | 2023-11-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-01 | 2023-11-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-20 | 2023-11-09 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-20 | 2023-11-09 | 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 | 2023-10-20 | 2023-11-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-20 | 2023-11-09 | 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 | 2023-10-20 | 2023-11-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-20 | 2023-11-09 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-10-20 | 2023-11-09 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2023-10-20 | 2023-11-09 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-10-20 | 2023-11-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-18 | 2023-09-18 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-04 | 2023-04-26 | Y |
| 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 | 2023-02-01 | 2023-03-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-30 | 2022-12-17 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-10-30 | 2022-12-17 | 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 | 2022-10-30 | 2022-12-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-30 | 2022-12-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-30 | 2022-12-17 | N |
| Post nurse staffing information every day. | Health | 2022-10-30 | 2022-12-17 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-10-30 | 2022-12-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-30 | 2022-12-17 | N |
| Dispose of garbage and refuse properly. | Health | 2022-10-30 | 2022-12-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-30 | 2022-12-17 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2022-10-30 | 2022-12-17 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-10-30 | 2022-12-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-03 | 2022-11-03 | Y |
| 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 | 2022-05-17 | 2022-05-31 | Y |
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