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Deficiency Records for The Pavilion On Main Street
A list of the most recent deficiencies for The Pavilion On Main Street. 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 The Pavilion On Main Street. 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? |
|---|---|---|---|---|
| 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 | 2024-06-26 | 2024-07-05 | Y |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-10-13 | 2023-11-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-28 | 2023-11-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-10-13 | 2023-11-03 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-10-13 | 2023-11-03 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-10-13 | 2023-11-03 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-10-13 | 2023-11-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-10-13 | 2023-11-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-13 | 2023-11-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-13 | 2023-11-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-13 | 2023-11-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-13 | 2023-11-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-13 | 2023-11-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-28 | 2023-10-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-28 | 2023-10-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-28 | 2023-10-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-28 | 2023-10-23 | 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 | 2023-09-28 | 2023-10-23 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-09-28 | 2023-10-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-28 | 2023-10-23 | 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 | 2023-09-28 | 2023-10-23 | 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 | 2023-09-28 | 2023-10-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-28 | 2023-10-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-17 | 2023-05-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-17 | 2023-05-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-02 | 2023-05-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-02 | 2023-05-12 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-01-17 | 2023-01-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-17 | 2023-01-31 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-17 | 2023-01-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-17 | 2023-01-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-17 | 2023-01-31 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-01-17 | 2023-01-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-17 | 2022-11-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-17 | 2022-11-29 | Y |
| 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 | 2022-11-17 | 2022-11-29 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-17 | 2022-11-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-17 | 2022-11-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-07 | 2022-11-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-02 | 2022-11-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-26 | 2022-11-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-26 | 2022-11-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-26 | 2022-10-15 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-26 | 2022-10-15 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-12 | 2022-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-12 | 2022-09-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-12 | 2022-09-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-12 | 2022-09-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-12 | 2022-09-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-28 | 2022-08-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-28 | 2022-08-15 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-07-28 | 2022-08-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-28 | 2022-08-15 | 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 | 2022-07-28 | 2022-08-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-28 | 2022-08-15 | N |
| Report COVID19 data to residents and families. | Health | 2022-07-28 | 2022-08-15 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-07-28 | 2022-08-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-28 | 2022-08-15 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-19 | 2022-05-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-04 | 2022-03-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-02 | 2021-12-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-18 | 2021-11-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-23 | 2021-10-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-23 | 2021-10-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-23 | 2021-10-13 | 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 | 2021-09-23 | 2021-10-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-23 | 2021-10-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-23 | 2021-10-13 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-09-23 | 2021-10-13 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-09-23 | 2021-10-13 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-09-23 | 2021-10-13 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-09-23 | 2021-10-13 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-09-23 | 2021-10-13 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-09-23 | 2021-10-13 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-09-23 | 2021-10-13 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-09-23 | 2021-10-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-09-23 | 2021-10-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-09-23 | 2021-10-13 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-09-23 | 2021-10-13 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-09-23 | 2021-10-13 | 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 | 2021-09-23 | 2021-10-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-23 | 2021-10-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-23 | 2021-10-13 | N |
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