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Deficiency Records for Pavilion Health Center at Brightmore
A list of the most recent deficiencies for Pavilion Health Center at Brightmore. 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 Health Center at Brightmore. 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 special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-04-23 | 2024-07-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-23 | 2024-07-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-23 | 2024-07-19 | N |
| Have an externally vented heating system. | Fire Safety | 2024-04-23 | 2024-07-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-23 | 2024-07-19 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-03-26 | 2024-04-18 | Y |
| 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 | 2024-03-26 | 2024-04-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-26 | 2024-04-18 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-03-26 | 2024-04-18 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-26 | 2024-04-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-26 | 2024-04-18 | 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 | 2024-03-26 | 2024-04-18 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-26 | 2024-04-18 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-03-26 | 2024-04-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-26 | 2024-04-18 | 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 | 2024-03-26 | 2024-04-18 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-26 | 2024-04-18 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-26 | 2024-04-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-26 | 2024-04-18 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-03-26 | 2024-04-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-26 | 2024-04-18 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-03-26 | 2024-04-18 | Y |
| Post nurse staffing information every day. | Health | 2024-03-26 | 2024-04-16 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-03-26 | 2024-03-26 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-16 | 2022-12-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-29 | 2022-10-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-29 | 2022-10-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-29 | 2022-10-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-29 | 2022-10-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-29 | 2022-10-17 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-26 | 2021-06-03 | N |
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