Deficiency Records for Pavilion On Pico Healthcare and Wellness Centre, LP
Updated as of April 01, 2024
A list of the most recent deficiencies for Pavilion On Pico Healthcare and Wellness Centre, LP. 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 pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-30 | 2024-02-16 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-01 | 2023-11-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-01 | 2023-11-22 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-11-01 | 2023-11-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-01 | 2023-11-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-01 | 2023-11-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-20 | 2023-11-09 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-20 | 2023-11-09 | 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 | 2023-10-20 | 2023-11-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-20 | 2023-11-09 | 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 | 2023-10-20 | 2023-11-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-20 | 2023-11-09 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-10-20 | 2023-11-09 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2023-10-20 | 2023-11-09 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-10-20 | 2023-11-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-18 | 2023-09-18 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-04 | 2023-04-26 | 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 | 2023-02-01 | 2023-03-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-30 | 2022-12-17 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-10-30 | 2022-12-17 | 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 | 2022-10-30 | 2022-12-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-30 | 2022-12-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-30 | 2022-12-17 | N |
| Post nurse staffing information every day. | Health | 2022-10-30 | 2022-12-17 | N |
| 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 | 2022-10-30 | 2022-12-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-30 | 2022-12-17 | N |
| Dispose of garbage and refuse properly. | Health | 2022-10-30 | 2022-12-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-30 | 2022-12-17 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2022-10-30 | 2022-12-17 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-10-30 | 2022-12-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-29 | 2022-12-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-03 | 2022-11-03 | 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 | 2022-05-17 | 2022-05-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-19 | 2022-03-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-08 | 2021-11-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-29 | 2021-08-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-29 | 2021-08-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-07-29 | 2021-08-30 | Y |
| 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 | 2021-07-29 | 2021-08-30 | 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 | 2021-07-29 | 2021-08-30 | 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 | 2021-07-29 | 2021-08-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-29 | 2021-08-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-29 | 2021-08-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-14 | 2021-07-29 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-05-31 | 2021-07-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-31 | 2021-07-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-31 | 2021-07-02 | Y |
| 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 | 2020-03-11 | 2020-04-01 | 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 | 2020-03-11 | 2020-04-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-03-11 | 2020-04-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-11 | 2020-04-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-03-11 | 2020-04-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-03-08 | 2020-03-31 | N |
| Respond appropriately to all alleged violations. | Health | 2020-03-08 | 2020-03-31 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2020-03-08 | 2020-03-31 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-03-08 | 2020-03-31 | 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 | 2020-03-08 | 2020-03-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-08 | 2020-03-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-08 | 2020-03-31 | 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 | 2020-03-08 | 2020-03-31 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2020-03-08 | 2020-03-31 | N |
| Dispose of garbage and refuse properly. | Health | 2020-03-08 | 2020-03-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-03-08 | 2020-03-31 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2020-03-08 | Not Fixed | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2020-03-08 | Not Fixed | N |
