Deficiency Records for The Pavilion
Updated as of August 01, 2019
This is not the most recent data for The Pavilion. For the most recent information, click here.
A list of the most recent deficiencies for The Pavilion. 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 each resident receives an accurate assessment. | Health | 2019-03-20 | 2019-04-30 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-29 | 2018-11-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-10-29 | 2018-11-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne | Health | 2018-10-29 | 2018-11-20 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-10-29 | 2018-11-20 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-10-24 | 2018-11-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-10-24 | 2018-11-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-07-19 | 2017-08-25 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-07-19 | 2017-08-18 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2017-07-19 | 2017-08-11 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2017-07-19 | 2017-07-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-06-19 | 2017-07-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-06-19 | 2017-07-21 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-06-19 | 2017-07-21 | 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 | 2017-06-19 | 2017-07-21 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-06-19 | 2017-07-21 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2017-06-19 | 2017-07-21 | N |
| Quickly tell the resident's doctor the results of laboratory tests. | Health | 2017-06-19 | 2017-07-21 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-06-19 | 2017-07-21 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-06-19 | 2017-06-30 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2016-03-29 | 2016-04-15 | N |
| An approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2016-03-29 | 2016-04-11 | 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 | 2016-03-09 | 2016-04-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2016-03-09 | 2016-04-08 | 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 | 2016-03-09 | 2016-04-08 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2016-03-09 | 2016-04-08 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-03-09 | 2016-04-08 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2016-03-29 | 2016-04-06 | N |
