A list of the most recent deficiencies for Harrison Pavilion Care Center. 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? |
|---|---|---|---|---|
| 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 | 2023-09-26 | 2024-01-17 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-09-26 | 2024-01-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-26 | 2024-01-09 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-26 | 2024-01-09 | 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 | 2023-09-26 | 2024-01-09 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-26 | 2024-01-09 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-09-26 | 2024-01-09 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-26 | 2024-01-09 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-09-26 | 2024-01-09 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-26 | 2024-01-09 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-26 | 2024-01-09 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-09-26 | 2024-01-09 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-26 | 2024-01-09 | Y |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-26 | 2024-01-09 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-26 | 2024-01-09 | Y |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-26 | 2024-01-09 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-03 | 2024-01-04 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-03 | 2024-01-04 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-10-03 | 2024-01-04 | Y |
| 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 | 2023-10-03 | 2024-01-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-03 | 2024-01-04 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-03 | 2024-01-04 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-10-03 | 2024-01-04 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-03 | 2024-01-04 | Y |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2023-10-03 | 2024-01-04 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-03 | 2024-01-04 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-10-03 | 2024-01-04 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-12-06 | 2023-11-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-06 | 2023-11-21 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-12-06 | 2023-11-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-08 | 2023-10-03 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-22 | 2023-06-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-31 | 2023-04-04 | Y |
| 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 | 2023-03-08 | 2023-04-04 | Y |
| 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 | 2023-03-08 | 2023-04-04 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-03-08 | 2023-04-04 | Y |
| 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 | 2022-08-10 | 2022-08-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-07 | 2022-07-07 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-02-25 | 2022-02-26 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-15 | 2022-02-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-15 | 2022-02-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-15 | 2022-02-26 | 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 | 2021-12-21 | 2022-02-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-21 | 2022-02-08 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-12-21 | 2022-02-08 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-12-21 | 2022-02-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-12-21 | 2022-02-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-21 | 2022-02-08 | 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 | 2021-12-21 | 2022-02-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-21 | 2022-02-08 | N |
| Provide activities to meet all resident's needs. | Health | 2021-12-21 | 2022-02-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-21 | 2022-02-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-21 | 2022-02-08 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-12-21 | 2022-02-08 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-12-21 | 2022-02-08 | 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 | 2021-12-21 | 2022-02-08 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-12-21 | 2022-02-08 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-12-21 | 2022-02-08 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-12-21 | 2022-02-08 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-12-21 | 2022-02-08 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2021-12-21 | 2022-02-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-21 | 2022-02-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-21 | 2022-02-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-21 | 2022-02-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-21 | 2022-02-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-21 | 2022-02-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-21 | 2022-02-08 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-21 | 2022-02-08 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-12-21 | 2022-02-08 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-21 | 2022-02-08 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-12-21 | 2022-02-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-21 | 2022-02-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-21 | 2022-02-08 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-21 | 2022-02-08 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-11-15 | 2022-02-08 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-11-15 | 2022-02-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-11-15 | 2022-02-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-11-15 | 2022-02-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-11-15 | 2022-02-08 | 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 | 2021-11-15 | 2022-02-08 | 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 | 2021-11-15 | 2022-02-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-15 | 2022-02-08 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-11-15 | 2022-02-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-15 | 2022-02-08 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-11-15 | 2022-02-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-15 | 2022-02-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-11-15 | 2022-02-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-15 | 2022-02-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-15 | 2022-02-08 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-11-15 | 2022-02-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-15 | 2022-02-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-27 | 2021-09-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-09-03 | 2021-09-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-03 | 2021-09-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-10 | 2021-05-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-03 | 2021-03-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-28 | 2019-04-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-03-28 | 2019-04-26 | 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 | 2019-03-28 | 2019-04-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-03-28 | 2019-04-26 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-03-28 | 2019-04-26 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-03-28 | 2019-04-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-28 | 2019-04-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-28 | 2019-04-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-28 | 2019-04-26 | 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 necessary and PRN use is limited. | Health | 2019-03-28 | 2019-04-26 | 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 | 2019-03-28 | 2019-04-26 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-03-28 | 2019-04-26 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-03-28 | 2019-04-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-28 | 2019-04-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-28 | 2019-04-26 | 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 | 2019-03-28 | 2019-04-26 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-03-28 | 2019-04-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-28 | 2019-04-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-28 | 2019-04-26 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-03-28 | 2019-04-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-28 | 2019-04-26 | N |
