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Deficiency Records for Pavilion of South Shore
A list of the most recent deficiencies for Pavilion of South Shore. 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 of South Shore. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-09-30 | 2024-10-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-30 | 2024-10-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-13 | 2024-06-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-19 | 2024-05-09 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-04-19 | 2024-05-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-19 | 2024-05-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-19 | 2024-05-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-19 | 2024-05-09 | 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 | 2024-04-19 | 2024-05-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-19 | 2024-05-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-04-19 | 2024-05-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-19 | 2024-05-09 | 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 | 2024-04-19 | 2024-05-09 | 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 | 2024-04-19 | 2024-05-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-19 | 2024-05-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-19 | 2024-05-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-12 | 2024-01-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-12 | 2024-01-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-12 | 2024-01-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-16 | 2023-11-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-16 | 2023-11-30 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-15 | 2023-04-01 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-03-15 | 2023-04-01 | 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 | 2023-03-15 | 2023-04-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-15 | 2023-04-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-15 | 2023-04-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-15 | 2023-04-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-15 | 2023-04-01 | 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 | 2023-03-15 | 2023-04-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-15 | 2023-04-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-15 | 2023-04-01 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-03-15 | 2023-04-01 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-03-15 | 2023-04-01 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2023-03-15 | 2023-04-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-19 | 2023-02-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-19 | 2023-02-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-19 | 2023-02-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-05 | 2022-12-14 | 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 | 2022-07-28 | 2022-08-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-25 | 2022-03-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-25 | 2022-03-10 | 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 | 2022-02-25 | 2022-03-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-25 | 2022-03-10 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-11-28 | 2021-12-06 | Y |
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