Deficiency Records for The Pavilion On Main Street
Updated as of October 01, 2016
This is not the most recent data for The Pavilion On Main Street. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-05-25 | 2016-06-01 | Y |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2016-05-25 | 2016-06-01 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-05-25 | 2016-06-01 | Y |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2016-05-25 | 2016-06-01 | Y |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Protected exits that allow the resident to escape the building. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| A fire alarm system that can be heard throughout the facility. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Properly protected cooking facilities. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Protected exits that allow the resident to escape the building. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| A fire alarm system that can be heard throughout the facility. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Properly protected cooking facilities. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-04-14 | 2016-05-09 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2016-04-19 | 2016-04-22 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-04-19 | 2016-04-22 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-04-19 | 2016-04-22 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2016-04-19 | 2016-04-22 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-04-19 | 2016-04-22 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2016-04-19 | 2016-04-22 | N |
| Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. | Health | 2016-04-19 | 2016-04-22 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2016-04-19 | 2016-04-22 | N |
| Provide food in a way that meets a resident's needs. | Health | 2016-04-19 | 2016-04-22 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-04-19 | 2016-04-22 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-04-19 | 2016-04-22 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2016-04-19 | 2016-04-22 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-04-19 | 2016-04-22 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-04-19 | 2016-04-22 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2016-04-19 | 2016-04-22 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-04-19 | 2016-04-22 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2016-04-19 | 2016-04-22 | N |
| Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. | Health | 2016-04-19 | 2016-04-22 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2016-04-19 | 2016-04-22 | N |
| Provide food in a way that meets a resident's needs. | Health | 2016-04-19 | 2016-04-22 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-04-19 | 2016-04-22 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-04-19 | 2016-04-22 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2015-09-17 | 2015-10-14 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2015-09-17 | 2015-10-14 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2015-09-17 | 2015-10-14 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2015-09-17 | 2015-10-14 | Y |
| Corridors that are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Proper stairway enclosures and vertical shafts. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Protected exits that allow the resident to escape the building. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Exits that are accessible at all times. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Properly maintained smoke detectors. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| The appropriate emergency electrical system. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Corridors that are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Proper stairway enclosures and vertical shafts. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Protected exits that allow the resident to escape the building. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Exits that are accessible at all times. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Properly maintained smoke detectors. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| The appropriate emergency electrical system. | Fire Safety | 2015-03-25 | 2015-05-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2015-03-18 | 2015-04-03 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2015-03-18 | 2015-04-03 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2015-03-18 | 2015-04-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2015-03-18 | 2015-04-03 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2015-03-18 | 2015-04-03 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2015-03-18 | 2015-04-03 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2015-03-18 | 2015-04-03 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2015-03-18 | 2015-04-03 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2015-03-18 | 2015-04-03 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2015-03-18 | 2015-04-03 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2015-03-18 | 2015-04-03 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2015-03-18 | 2015-04-03 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2015-03-18 | 2015-04-03 | N |
| Ensure that all full-time nurse aids employed for more than 4 months are fully trained and competent to provide nursing and nursing-related services, as defined by Federal requirements. | Health | 2015-03-18 | 2015-04-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2015-03-18 | 2015-04-03 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2015-03-18 | 2015-04-03 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2015-03-18 | 2015-04-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2015-03-18 | 2015-04-03 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2015-03-18 | 2015-04-03 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2015-03-18 | 2015-04-03 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2015-03-18 | 2015-04-03 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2015-03-18 | 2015-04-03 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2015-03-18 | 2015-04-03 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2015-03-18 | 2015-04-03 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2015-03-18 | 2015-04-03 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2015-03-18 | 2015-04-03 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2015-03-18 | 2015-04-03 | N |
| Ensure that all full-time nurse aids employed for more than 4 months are fully trained and competent to provide nursing and nursing-related services, as defined by Federal requirements. | Health | 2015-03-18 | 2015-04-03 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2014-06-24 | 2014-06-24 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2014-06-24 | 2014-06-24 | Y |
| Corridors that are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Proper stairway enclosures and vertical shafts. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Protected exits that allow the resident to escape the building. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| A fire alarm system that can be heard throughout the facility. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| An approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Properly maintained smoke detectors. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Properly protected cooking facilities. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2014-05-06 | 2014-05-30 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2014-05-06 | 2014-05-30 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2014-05-06 | 2014-05-30 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2014-05-06 | 2014-05-30 | N |
| Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2014-05-06 | 2014-05-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2014-05-06 | 2014-05-30 | N |
| Give notice to the resident before a room or roommate change. | Health | 2014-05-06 | 2014-05-30 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2014-05-06 | 2014-05-30 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2014-05-06 | 2014-05-30 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2014-05-06 | 2014-05-30 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2014-05-06 | 2014-05-30 | N |
| Offer other nutritional food to each resident who will not eat the food served. | Health | 2014-05-06 | 2014-05-30 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2014-05-06 | 2014-05-30 | N |
| Corridors that are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Proper stairway enclosures and vertical shafts. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Protected exits that allow the resident to escape the building. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| A fire alarm system that can be heard throughout the facility. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| An approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Properly maintained smoke detectors. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Properly protected cooking facilities. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2014-05-08 | 2014-05-30 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2014-05-06 | 2014-05-30 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2014-05-06 | 2014-05-30 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2014-05-06 | 2014-05-30 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2014-05-06 | 2014-05-30 | N |
| Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2014-05-06 | 2014-05-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2014-05-06 | 2014-05-30 | N |
| Give notice to the resident before a room or roommate change. | Health | 2014-05-06 | 2014-05-30 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2014-05-06 | 2014-05-30 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2014-05-06 | 2014-05-30 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2014-05-06 | 2014-05-30 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2014-05-06 | 2014-05-30 | N |
| Offer other nutritional food to each resident who will not eat the food served. | Health | 2014-05-06 | 2014-05-30 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2014-05-06 | 2014-05-30 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2013-10-23 | 2013-10-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2013-10-23 | 2013-10-23 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2013-10-09 | 2013-10-10 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2013-10-09 | 2013-10-10 | Y |
