Deficiency Records for The Pavilion On Main Street
Updated as of September 01, 2018
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? |
|---|---|---|---|---|
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-05-31 | 2018-06-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-16 | 2018-05-07 | 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 | 2018-03-16 | 2018-05-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-02-16 | 2018-04-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-02-16 | 2018-04-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-02-16 | 2018-04-20 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-03-16 | 2018-04-20 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-03-16 | 2018-04-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-16 | 2018-04-20 | 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 | 2018-03-16 | 2018-04-20 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-03-16 | 2018-04-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-16 | 2018-04-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-03-16 | 2018-04-20 | 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 | 2018-03-16 | 2018-04-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-16 | 2018-04-20 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-03-16 | 2018-04-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-16 | 2018-04-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-16 | 2018-04-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-03-16 | 2018-04-20 | N |
| Post nurse staffing information every day. | Health | 2018-03-16 | 2018-04-13 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-03-16 | 2018-03-22 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-03-16 | 2018-03-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-03-16 | 2018-03-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-03-16 | 2018-03-17 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2018-03-16 | 2018-03-17 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-10-12 | 2017-10-24 | Y |
| 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 | 2017-10-12 | 2017-10-24 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-10-12 | 2017-10-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-29 | 2017-09-05 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-07-05 | 2017-07-06 | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-07-05 | 2017-07-06 | Y |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-06-07 | 2017-06-20 | Y |
| 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 | 2017-06-07 | 2017-06-20 | Y |
| 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 | 2017-06-07 | 2017-06-20 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-02-22 | 2017-03-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-02-22 | 2017-03-20 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2017-02-22 | 2017-03-20 | 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 | 2017-02-22 | 2017-03-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-02-22 | 2017-03-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-02-22 | 2017-03-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-02-22 | 2017-03-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-02-22 | 2017-03-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-02-22 | 2017-03-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-02-22 | 2017-03-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-02-22 | 2017-03-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-02-22 | 2017-03-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-02-22 | 2017-03-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-02-22 | 2017-03-16 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-02-16 | 2017-03-10 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-02-16 | 2017-03-10 | 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 | 2017-02-16 | 2017-03-10 | 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 | 2017-02-16 | 2017-03-10 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-02-16 | 2017-03-10 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-02-16 | 2017-03-10 | N |
| 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 |
| 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 |
