Deficiency Records for The Pavilion On Main Street

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Updated as of March 01, 2024

A list of the most recent deficiencies for The Pavilion On Main Street. 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 a battery powered remote alarm panel in a location accessible by operating personnel. Fire Safety 2023-10-13 2023-11-22 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
Address subsistence needs for staff and patients. Fire Safety 2023-10-13 2023-11-03 N
Establish policies and procedures for sheltering. Fire Safety 2023-10-13 2023-11-03 N
Establish policies and procedures for medical documentation. Fire Safety 2023-10-13 2023-11-03 N
Establish roles under a Waiver declared by secretary. Fire Safety 2023-10-13 2023-11-03 N
Implement emergency and standby power systems. Fire Safety 2023-10-13 2023-11-03 N
Install an approved automatic sprinkler system. Fire Safety 2023-10-13 2023-11-03 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-10-13 2023-11-03 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-10-13 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 2023-10-13 2023-11-03 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-10-13 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 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 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 2023-05-17 2023-05-31 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-05-17 2023-05-31 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
Ensure that residents are free from significant medication errors. Health 2023-05-02 2023-05-12 Y
Keep residents' personal and medical records private and confidential. Health 2023-01-17 2023-01-31 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-01-17 2023-01-31 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-01-17 2023-01-31 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-01-17 2023-01-31 Y
Respond appropriately to all alleged violations. Health 2023-01-17 2023-01-31 Y
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2023-01-17 2023-01-31 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-11-17 2022-11-29 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-11-17 2022-11-29 Y
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 2022-11-17 2022-11-29 Y
Provide enough food/fluids to maintain a resident's health. Health 2022-11-17 2022-11-29 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-11-17 2022-11-29 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-11-07 2022-11-17 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-11-02 2022-11-12 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-09-26 2022-11-10 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-09-26 2022-11-09 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-09-26 2022-10-15 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2022-09-26 2022-10-15 Y
Establish staff and initial training requirements. Fire Safety 2022-08-12 2022-09-12 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-08-12 2022-09-12 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2022-08-12 2022-09-12 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2022-08-12 2022-09-12 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-08-12 2022-09-12 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-07-28 2022-08-15 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-07-28 2022-08-15 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 2022-07-28 2022-08-15 N
Ensure that residents are free from significant medication errors. Health 2022-07-28 2022-08-15 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 2022-07-28 2022-08-15 N
Provide and implement an infection prevention and control program. Health 2022-07-28 2022-08-15 N
Report COVID19 data to residents and families. Health 2022-07-28 2022-08-15 N
Perform COVID19 testing on residents and staff. Health 2022-07-28 2022-08-15 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-07-28 2022-08-15 Y
Provide properly protected cooking facilities. Fire Safety 2022-04-19 2022-05-02 Y
Provide and implement an infection prevention and control program. Health 2022-02-04 2022-03-02 N
Provide and implement an infection prevention and control program. Health 2021-12-02 2021-12-16 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-11-18 2021-11-30 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-10-05 2021-10-13 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-09-23 2021-10-13 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-09-23 2021-10-13 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2021-09-23 2021-10-13 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 2021-09-23 2021-10-13 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-09-23 2021-10-13 N
Provide and implement an infection prevention and control program. Health 2021-09-23 2021-10-13 N
Address patient/client population and determine types of services needed. Fire Safety 2021-09-23 2021-10-13 N
Address subsistence needs for staff and patients. Fire Safety 2021-09-23 2021-10-13 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2021-09-23 2021-10-13 N
Establish policies and procedures for sheltering. Fire Safety 2021-09-23 2021-10-13 N
Establish policies and procedures for volunteers. Fire Safety 2021-09-23 2021-10-13 N
Create arrangements with other facilities to receive patients. Fire Safety 2021-09-23 2021-10-13 N
Provide primary/alternate means for communication. Fire Safety 2021-09-23 2021-10-13 N
Establish emergency prep training and testing. Fire Safety 2021-09-23 2021-10-13 N
Establish staff and initial training requirements. Fire Safety 2021-09-23 2021-10-13 N
Conduct testing and exercise requirements. Fire Safety 2021-09-23 2021-10-13 N
Implement emergency and standby power systems. Fire Safety 2021-09-23 2021-10-13 N
Have an enclosure around a vertical opening shaft. Fire Safety 2021-09-23 2021-10-13 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 2021-09-23 2021-10-13 N
Install corridor and hallway doors that block smoke. Fire Safety 2021-09-23 2021-10-13 N
Ensure proper usage of power strips and extension cords. Fire Safety 2021-09-23 2021-10-13 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-08-27 2021-09-10 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2021-08-25 2021-09-01 Y
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 2021-08-25 2021-09-01 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2021-05-18 2021-06-08 Y