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Deficiency Records for The Pavilion at Sunny Hills
A list of the most recent deficiencies for The Pavilion at Sunny Hills. 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 at Sunny Hills. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-30 | 2024-08-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-28 | 2024-06-28 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-12-11 | 2024-01-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-11 | 2024-01-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-12-11 | 2024-01-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-11 | 2024-01-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-12-11 | 2024-01-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-11 | 2024-01-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-12-11 | 2024-01-08 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-12-07 | 2024-01-07 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-12-07 | 2024-01-07 | 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 | 2023-12-07 | 2024-01-07 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-12-07 | 2024-01-07 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-12-07 | 2024-01-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-07 | 2024-01-07 | 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 | 2023-12-07 | 2024-01-07 | N |
| Provide activities to meet all resident's needs. | Health | 2023-12-07 | 2024-01-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-07 | 2024-01-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-07 | 2024-01-07 | 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 | 2023-12-07 | 2024-01-07 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-12-07 | 2024-01-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-07 | 2024-01-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-07 | 2024-01-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-07 | 2024-01-07 | 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 | 2023-12-07 | 2024-01-07 | 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 | 2023-12-07 | 2024-01-07 | 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 | 2023-12-07 | 2024-01-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-07 | 2024-01-07 | N |
| Dispose of garbage and refuse properly. | Health | 2023-12-07 | 2024-01-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-07 | 2024-01-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-12-07 | 2024-01-07 | N |
| Keep all essential equipment working safely. | Health | 2023-12-07 | 2024-01-07 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-12-07 | 2024-01-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-09 | 2023-12-08 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-08-29 | 2023-09-29 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-08-29 | 2023-09-29 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-07-05 | 2023-07-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-14 | 2023-07-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-14 | 2023-07-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-28 | 2022-05-27 | Y |
| 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 | 2022-04-28 | 2022-05-27 | Y |
| 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 | 2022-03-04 | 2022-03-18 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2021-11-15 | 2021-12-17 | N |
| Use approved construction type or materials. | Fire Safety | 2021-11-15 | 2021-12-17 | N |
| 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 | 2021-11-15 | 2021-12-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-15 | 2021-12-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-11-15 | 2021-12-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-15 | 2021-12-17 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-11-15 | 2021-12-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-15 | 2021-12-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-16 | 2021-12-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-16 | 2021-12-15 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-11-16 | 2021-12-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-16 | 2021-12-15 | N |
| Provide activities to meet all resident's needs. | Health | 2021-11-16 | 2021-12-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-16 | 2021-12-15 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-11-16 | 2021-12-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-16 | 2021-12-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-11-16 | 2021-12-15 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-11-16 | 2021-12-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-16 | 2021-12-15 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-11-16 | 2021-12-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-16 | 2021-12-15 | N |
| Keep all essential equipment working safely. | Health | 2021-11-16 | 2021-12-15 | 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 | 2021-11-16 | 2021-12-15 | Y |
| Dispose of garbage and refuse properly. | Health | 2021-11-16 | 2021-12-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-16 | 2021-12-15 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-29 | 2020-02-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-29 | 2020-02-24 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2020-01-29 | 2020-02-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-29 | 2020-02-24 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2020-01-29 | 2020-02-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-29 | 2020-02-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-22 | 2020-02-22 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-01-22 | 2020-02-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-22 | 2020-02-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-22 | 2020-02-22 | 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 | 2020-01-22 | 2020-02-22 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-01-22 | 2020-02-22 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2020-01-22 | 2020-02-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-22 | 2020-02-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-01-22 | 2020-02-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-22 | 2020-02-22 | 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 | 2020-01-22 | 2020-02-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-01-22 | 2020-02-22 | 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 | 2020-01-22 | 2020-02-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-22 | 2020-02-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-22 | 2020-02-22 | N |
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