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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?
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
Provide and implement an infection prevention and control program. Health 2022-02-19 2022-03-15 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-11-08 2021-11-29 Y
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2020-03-11 2020-04-01 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2020-03-11 2020-04-01 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2020-03-11 2020-04-01 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2020-03-11 2020-04-01 N
Have proper medical gas storage and administration areas. Fire Safety 2020-03-11 2020-04-01 N
Reasonably accommodate the needs and preferences of each resident. Health 2020-03-08 2020-03-31 N
Respond appropriately to all alleged violations. Health 2020-03-08 2020-03-31 N
Assure that each resident?s assessment is updated at least once every 3 months. Health 2020-03-08 2020-03-31 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2020-03-08 2020-03-31 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 2020-03-08 2020-03-31 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2020-03-08 2020-03-31 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2020-03-08 2020-03-31 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 2020-03-08 2020-03-31 N
Have a policy regarding use and storage of foods brought to residents by family and other visitors. Health 2020-03-08 2020-03-31 N
Dispose of garbage and refuse properly. Health 2020-03-08 2020-03-31 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2020-03-08 2020-03-31 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 2020-03-08 Not Fixed N
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Health 2020-03-08 Not Fixed N

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