A list of the most recent deficiencies for The Pavilion at Crescent Lake. 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? |
|---|---|---|---|---|
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-11-13 | 2023-12-22 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-21 | 2023-06-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-21 | 2023-06-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-23 | 2023-05-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-03-23 | 2023-05-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-23 | 2023-05-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-23 | 2023-05-03 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-03-21 | 2023-05-03 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-03-21 | 2023-05-03 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-03-21 | 2023-05-03 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-03-21 | 2023-05-03 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-03-21 | 2023-05-03 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-03-21 | 2023-05-03 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-03-21 | 2023-05-03 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-03-21 | 2023-05-03 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-03-21 | 2023-05-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-21 | 2023-05-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-21 | 2023-05-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-21 | 2023-05-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-03-21 | 2023-05-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-21 | 2023-05-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-21 | 2023-05-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-21 | 2023-05-03 | 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 | 2021-10-07 | 2021-11-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-07 | 2021-11-08 | 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 | 2021-10-07 | 2021-11-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-07 | 2021-11-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-07 | 2021-11-08 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-10-07 | 2021-11-08 | Y |
| Report COVID19 data to residents and families. | Health | 2021-09-20 | 2021-10-20 | 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 | 2020-02-12 | 2020-06-08 | 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 | 2020-02-12 | 2020-04-07 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-02-12 | 2020-04-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-12 | 2020-04-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-12 | 2020-04-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-12 | 2020-04-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-12 | 2020-04-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-12 | 2020-04-07 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-02-12 | 2020-04-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-17 | 2020-04-07 | N |
| Have exits that are accessible at all times. | Fire Safety | 2020-02-17 | 2020-04-07 | N |
| Install proper backup exit lighting. | Fire Safety | 2020-02-17 | 2020-04-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-17 | 2020-04-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-17 | 2020-04-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-17 | 2020-04-07 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2020-02-17 | 2020-04-07 | N |
