A list of the most recent deficiencies for The Ball 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? |
|---|---|---|---|---|
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-05-23 | 2023-07-14 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-05-23 | 2023-07-14 | 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 | 2023-05-23 | 2023-07-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-23 | 2023-07-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-23 | 2023-07-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-23 | 2023-07-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-23 | 2023-07-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-23 | 2023-07-14 | 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 | 2023-05-12 | 2023-07-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-12 | 2023-07-11 | 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 | 2023-05-12 | 2023-07-11 | 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 | 2023-05-12 | 2023-07-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-12 | 2023-07-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-12 | 2023-07-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-12 | 2023-07-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-16 | 2022-08-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-16 | 2022-08-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-16 | 2022-08-08 | 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 | 2022-06-16 | 2022-08-08 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-06-16 | 2022-08-08 | N |
| Meet other general requirements. | Fire Safety | 2022-06-14 | 2022-06-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-14 | 2022-06-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-14 | 2022-06-23 | 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 | 2021-08-20 | 2021-10-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-20 | 2021-10-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-20 | 2021-10-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-20 | 2021-10-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-20 | 2021-10-15 | N |
| Provide or obtain dental services for each resident. | Health | 2021-08-20 | 2021-10-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-20 | 2021-10-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-20 | 2021-10-15 | N |
| Meet other general requirements. | Fire Safety | 2021-08-24 | 2021-09-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-24 | 2021-09-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-24 | 2021-09-30 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-08-24 | 2021-09-30 | N |
