A list of the most recent deficiencies for The Pavilion at Piketon. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-29 | 2024-02-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-29 | 2024-02-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-01-29 | 2024-02-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-29 | 2024-02-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-29 | 2024-02-22 | 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 | 2024-01-29 | 2024-02-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-29 | 2024-02-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-29 | 2024-02-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-29 | 2024-02-22 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-01-29 | 2024-02-22 | 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 | 2024-01-29 | 2024-02-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-29 | 2024-02-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-29 | 2024-02-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-29 | 2024-02-22 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-29 | 2024-02-22 | Y |
| 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 | 2024-01-18 | 2024-02-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-18 | 2024-02-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-18 | 2024-02-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-18 | 2024-02-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-18 | 2024-02-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-18 | 2024-02-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-18 | 2023-04-20 | 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 | 2022-05-19 | 2022-07-01 | 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 | 2022-05-19 | 2022-07-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-19 | 2022-07-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-19 | 2022-07-01 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-05-19 | 2022-07-01 | 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 | 2022-05-19 | 2022-07-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-05-19 | 2022-07-01 | 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 | 2022-05-17 | 2022-07-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-17 | 2022-07-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-05-17 | 2022-07-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-17 | 2022-07-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-17 | 2022-07-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-05-17 | 2022-07-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-05-17 | 2022-07-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-17 | 2022-07-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-17 | 2022-07-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-14 | 2021-09-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-07 | 2019-12-03 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-07 | 2019-12-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-07 | 2019-12-03 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-11-07 | 2019-12-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-07 | 2019-12-03 | 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 | 2019-11-07 | 2019-12-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-07 | 2019-12-03 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-11-07 | 2019-12-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-07 | 2019-12-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-11-07 | 2019-12-03 | 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 | 2019-11-07 | 2019-12-03 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-11-07 | 2019-12-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-05 | 2019-12-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-05 | 2019-12-03 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-11-05 | 2019-12-03 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-11-05 | 2019-12-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-05 | 2019-12-03 | N |
