A list of the most recent deficiencies for The Pavilion at Brmc. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-05 | 2024-03-01 | 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 | 2024-01-05 | 2024-03-01 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-01-05 | 2024-03-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-05 | 2024-03-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-05 | 2024-03-01 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-01-05 | 2024-03-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-05 | 2024-03-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-01-18 | 2024-02-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-18 | 2024-02-16 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-02-16 | 2023-04-17 | 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 | 2023-02-16 | 2023-04-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-16 | 2023-04-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-16 | 2023-04-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-16 | 2023-04-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-16 | 2023-04-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-16 | 2023-04-04 | 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 | 2023-02-16 | 2023-04-04 | 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 | 2023-02-16 | 2023-04-04 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-03-11 | 2022-05-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-11 | 2022-05-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-11 | 2022-05-02 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-03-30 | 2022-05-02 | 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 | 2022-03-30 | 2022-05-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-30 | 2022-05-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-30 | 2022-05-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-30 | 2021-05-31 | N |
