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Deficiency Records for The Pavilion On Main Street
View the most recent health deficiencies and inspection results for The Pavilion On Main Street. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for The Pavilion On Main Street. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-09-18 | 2025-11-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-10-09 | 2025-10-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-09-18 | 2025-09-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-08-27 | 2025-09-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-08-27 | 2025-09-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2025-08-27 | 2025-09-23 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2025-08-27 | 2025-09-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2025-08-27 | 2025-09-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-08-27 | 2025-09-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-08-27 | 2025-09-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-08-27 | 2025-09-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-08-27 | 2025-09-23 | 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 | 2025-08-27 | 2025-09-23 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2025-07-23 | 2025-08-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-07-23 | 2025-08-05 | Y |
| Install proper backup exit lighting. | Fire Safety | 2024-10-30 | 2024-12-13 | 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 | 2024-10-30 | 2024-12-13 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-10-30 | 2024-12-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-10-30 | 2024-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-30 | 2024-12-13 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-10-30 | 2024-12-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-10-30 | 2024-12-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-10-30 | 2024-11-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-10-30 | 2024-11-11 | 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 | 2024-06-26 | 2024-07-05 | Y |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-09-28 | 2023-11-22 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-09-28 | 2023-11-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-28 | 2023-11-03 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-09-28 | 2023-11-03 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-09-28 | 2023-11-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-28 | 2023-11-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-28 | 2023-11-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-28 | 2023-11-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-09-28 | 2023-11-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-28 | 2023-11-03 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-09-28 | 2023-11-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-09-28 | 2023-11-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-28 | 2023-10-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-28 | 2023-10-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-28 | 2023-10-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-28 | 2023-10-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-28 | 2023-10-23 | 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 | 2023-09-28 | 2023-10-23 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-09-28 | 2023-10-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-28 | 2023-10-23 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-09-28 | 2023-10-23 | 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 | 2023-09-28 | 2023-10-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-17 | 2023-05-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-17 | 2023-05-31 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-02 | 2023-05-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-02 | 2023-05-12 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-10-30 | Not Fixed | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-10-30 | Not Fixed | N |