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Deficiency Records for The Pavilion Rehabilitation and Nursing Center
A list of the most recent deficiencies for The Pavilion Rehabilitation and Nursing Center. 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 Rehabilitation and Nursing Center. 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 | 2024-08-19 | 2024-08-23 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2024-06-26 | 2024-07-12 | 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 | 2024-06-26 | 2024-07-12 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-06-26 | 2024-07-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-26 | 2024-07-12 | Y |
| Keep all essential equipment working safely. | Health | 2024-06-26 | 2024-07-12 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-05-15 | 2024-06-03 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-15 | 2024-06-03 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-05-15 | 2024-06-03 | 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 | 2024-03-22 | 2024-04-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-22 | 2024-04-05 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-03-22 | 2024-04-05 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-03-21 | 2023-04-13 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-03-21 | 2023-04-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-21 | 2023-04-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-21 | 2023-04-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-21 | 2023-04-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-21 | 2023-04-13 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-03-21 | 2023-04-13 | Y |
| 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 | 2023-03-21 | 2023-04-13 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-21 | 2023-04-13 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-21 | 2023-04-13 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-21 | 2023-04-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-21 | 2023-04-13 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-21 | 2023-04-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-02 | 2023-02-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-24 | 2022-11-18 | 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 | 2022-10-24 | 2022-11-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-24 | 2022-11-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-24 | 2022-11-18 | N |
| 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 | 2022-10-24 | 2022-11-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-24 | 2022-11-18 | 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 | 2022-10-24 | 2022-11-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-24 | 2022-11-18 | N |
| Provide activities to meet all resident's needs. | Health | 2022-10-24 | 2022-11-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-24 | 2022-11-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-24 | 2022-11-18 | 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 | 2022-10-24 | 2022-11-18 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-10-24 | 2022-11-18 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-10-24 | 2022-11-18 | 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 | 2022-10-24 | 2022-11-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-24 | 2022-11-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-24 | 2022-11-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-24 | 2022-11-18 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-10-03 | 2022-11-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-03 | 2022-11-18 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-10-03 | 2022-11-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-03 | 2022-11-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-03 | 2022-11-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-10-03 | 2022-11-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-03 | 2022-11-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-03 | 2022-11-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-03 | 2022-11-18 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-07-07 | 2022-07-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-20 | 2022-04-13 | 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 | 2021-12-13 | 2022-04-13 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-16 | 2022-04-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-16 | 2022-04-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-16 | 2022-04-06 | 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 | 2022-02-16 | 2022-04-06 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-16 | 2022-04-06 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-02-16 | 2022-04-06 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-12-28 | 2022-04-06 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-12-28 | 2022-04-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-28 | 2022-04-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-13 | 2022-04-06 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-31 | 2019-11-29 | 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 | 2019-10-31 | 2019-11-29 | 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 | 2019-10-31 | 2019-11-29 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-31 | 2019-11-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-31 | 2019-11-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-31 | 2019-11-29 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-10-31 | 2019-11-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-10-31 | 2019-11-29 | N |
| Have policies on smoking. | Health | 2019-10-31 | 2019-11-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-29 | 2019-11-29 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-10-29 | 2019-11-29 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-10-29 | 2019-11-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-29 | 2019-11-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-29 | 2019-11-29 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-10-29 | 2019-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-29 | 2019-11-29 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-10-29 | 2019-11-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-29 | 2019-11-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-10-29 | 2019-11-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-29 | 2019-11-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-29 | 2019-11-29 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-10-29 | 2019-11-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-20 | 2018-11-16 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-09-20 | 2018-11-16 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-09-20 | 2018-11-16 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-09-20 | 2018-11-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-09-20 | 2018-11-16 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-09-20 | 2018-11-16 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2018-09-20 | 2018-11-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-09-20 | 2018-11-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-09-20 | 2018-11-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-20 | 2018-11-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-09-20 | 2018-11-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-09-20 | 2018-11-16 | N |
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