A list of the most recent deficiencies for The Pavilion at Ocean Point. 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 residents are free from significant medication errors. | Health | 2024-01-25 | 2024-02-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-21 | 2024-01-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-21 | 2024-01-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-26 | 2023-12-05 | 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 | 2023-10-26 | 2023-12-05 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-26 | 2023-12-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-26 | 2023-12-05 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-10-26 | 2023-12-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-26 | 2023-12-05 | N |
| Use approved construction type or materials. | Fire Safety | 2023-10-31 | 2023-11-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-31 | 2023-11-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-31 | 2023-11-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-31 | 2023-11-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-31 | 2023-11-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-31 | 2023-11-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-02 | 2023-10-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-24 | 2023-10-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-24 | 2023-10-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-24 | 2023-10-11 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-09-14 | 2023-10-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-14 | 2023-10-11 | 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 | 2023-09-14 | 2023-10-11 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-09-18 | 2023-10-09 | 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 | 2023-08-03 | 2023-08-31 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-01 | 2023-08-31 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-08-04 | 2023-08-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-19 | 2023-07-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-19 | 2023-07-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-19 | 2023-07-19 | 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 | 2023-04-21 | 2023-05-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-12 | 2023-04-30 | Y |
| 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 | 2023-02-28 | 2023-03-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-22 | 2023-03-28 | 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 | 2023-02-07 | 2023-03-15 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-03 | 2023-01-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-17 | 2023-01-23 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-10-19 | 2022-11-19 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-10-19 | 2022-11-19 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-10-19 | 2022-11-19 | N |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2022-10-19 | 2022-11-19 | 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 | 2022-10-19 | 2022-11-19 | 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 | 2022-10-19 | 2022-11-19 | 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 | 2022-10-19 | 2022-11-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-19 | 2022-11-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-19 | 2022-11-19 | 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 | 2022-10-19 | 2022-11-19 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-10-19 | 2022-11-19 | 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 | 2022-10-19 | 2022-11-19 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-10-19 | 2022-11-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-10-19 | 2022-11-19 | N |
| Post nurse staffing information every day. | Health | 2022-10-19 | 2022-11-19 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-10-19 | 2022-11-19 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-10-19 | 2022-11-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-19 | 2022-11-19 | 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 | 2022-10-19 | 2022-11-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-19 | 2022-11-19 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-10-19 | 2022-11-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-10-19 | 2022-11-19 | N |
| Keep all essential equipment working safely. | Health | 2022-10-19 | 2022-11-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-10-18 | 2022-11-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-18 | 2022-11-14 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-10-18 | 2022-11-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-18 | 2022-11-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-18 | 2022-11-14 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-10-18 | 2022-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-18 | 2022-11-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-18 | 2022-11-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-18 | 2022-11-14 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2022-10-18 | 2022-11-14 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-10-18 | 2022-11-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-18 | 2022-11-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-18 | 2022-11-14 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-10-18 | 2022-11-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-15 | 2022-10-31 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-29 | 2022-10-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-29 | 2022-10-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-29 | 2022-10-29 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-09-16 | 2022-09-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-16 | 2022-09-23 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-06-11 | 2022-06-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-27 | 2022-06-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-05 | 2022-06-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-01 | 2022-03-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-21 | 2022-02-22 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-09-14 | 2021-10-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-14 | 2021-10-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-14 | 2021-10-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-14 | 2021-10-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-14 | 2021-10-20 | 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 | 2021-04-16 | 2021-05-20 | Y |
| 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 | 2021-04-16 | 2021-05-20 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-08-07 | 2019-09-20 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-08-07 | 2019-09-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-07 | 2019-09-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-08-07 | 2019-09-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-07 | 2019-09-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-07 | 2019-09-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-18 | 2019-08-18 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-07-18 | 2019-08-18 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-07-18 | 2019-08-18 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-07-18 | 2019-08-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-18 | 2019-08-18 | 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 | 2019-07-18 | 2019-08-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-18 | 2019-08-18 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-07-18 | 2019-08-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-01 | Not Fixed | 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 | 2021-09-01 | Not Fixed | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-09-01 | Not Fixed | N |
| Report COVID19 data to residents and families. | Health | 2021-09-01 | Not Fixed | N |
