Deficiency Records for The Pavilion On Main Street
Updated as of April 01, 2021
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? |
|---|---|---|---|---|
| Establish staff and initial training requirements. | Fire Safety | 2020-09-03 | 2020-09-24 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-09-03 | 2020-09-21 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-09-03 | 2020-09-21 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-09-03 | 2020-09-21 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2020-09-03 | 2020-09-21 | N |
| Develop a communication plan. | Fire Safety | 2020-09-03 | 2020-09-21 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-09-03 | 2020-09-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-09-03 | 2020-09-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-09-03 | 2020-09-21 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2020-09-03 | 2020-09-21 | 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 | 2020-09-03 | 2020-09-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-09-03 | 2020-09-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-09-03 | 2020-09-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-09-03 | 2020-09-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-09-03 | 2020-09-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-08-11 | 2020-08-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-08-11 | 2020-08-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-07-29 | 2020-08-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-07-22 | 2020-08-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-03-12 | 2020-04-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-03-12 | 2020-04-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-12 | 2020-04-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-12 | 2020-04-03 | 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 | 2020-03-12 | 2020-04-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-03-12 | 2020-04-03 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-03-12 | 2020-04-03 | N |
| Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. | Health | 2020-03-12 | 2020-04-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-12 | 2020-04-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-12 | 2020-04-03 | 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 | 2020-02-20 | 2020-03-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-15 | 2019-10-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-01 | 2019-08-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-01 | 2019-08-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-03 | 2019-07-26 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-04-16 | 2019-05-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-16 | 2019-05-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-04-16 | 2019-05-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-16 | 2019-05-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-16 | 2019-05-20 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-04-16 | 2019-05-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-16 | 2019-05-20 | N |
| 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 | 2019-04-11 | 2019-05-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-11 | 2019-05-07 | 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 | 2019-04-11 | 2019-05-07 | N |
| Provide activities to meet all resident's needs. | Health | 2019-04-11 | 2019-05-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-11 | 2019-05-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-11 | 2019-05-07 | 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 | 2019-04-11 | 2019-05-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-11 | 2019-05-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-11 | 2019-05-07 | N |
| Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. | Health | 2019-04-11 | 2019-05-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-11 | 2019-05-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-25 | 2019-03-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-13 | 2019-03-04 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-02-13 | 2019-03-04 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-02-13 | 2019-03-04 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-10-03 | 2018-12-07 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-03 | 2018-12-07 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2018-10-03 | 2018-12-07 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-10-03 | 2018-11-01 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-09-21 | 2018-10-01 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-09-21 | 2018-10-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-08-08 | 2018-09-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-08 | 2018-09-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-08 | 2018-09-07 | Y |
| 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 |
| 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 |
