Deficiency Records for Care Pavilion Nursing and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Care Pavilion Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-19 | 2024-02-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-01-19 | 2024-02-28 | 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 | 2024-01-19 | 2024-02-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-19 | 2024-02-28 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-01-19 | 2024-02-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-19 | 2024-02-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-19 | 2024-02-28 | 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 | 2024-01-19 | 2024-02-28 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-01-19 | 2024-02-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-01-19 | 2024-02-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-19 | 2024-02-28 | 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 | 2024-01-19 | 2024-02-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-19 | 2024-02-28 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-01-19 | 2024-02-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-19 | 2024-02-28 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-01-19 | 2024-02-28 | N |
| Provide or obtain dental services for each resident. | Health | 2024-01-19 | 2024-02-28 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-01-19 | 2024-02-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-19 | 2024-02-28 | N |
| Dispose of garbage and refuse properly. | Health | 2024-01-19 | 2024-02-28 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-01-19 | 2024-02-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-19 | 2024-02-28 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-01-19 | 2024-02-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-19 | 2024-02-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-19 | 2024-02-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-19 | 2024-02-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-26 | 2024-02-24 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2024-01-16 | 2024-02-08 | 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 | 2024-01-16 | 2024-02-08 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-01-16 | 2024-02-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-01-16 | 2024-02-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-16 | 2024-02-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-16 | 2024-02-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-16 | 2024-02-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-16 | 2024-02-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-16 | 2024-02-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-16 | 2024-02-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-16 | 2024-02-08 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-01-16 | 2024-02-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-16 | 2024-02-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-02 | 2023-11-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-02 | 2023-11-17 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-09-20 | 2023-10-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-20 | 2023-10-03 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-09-20 | 2023-10-03 | 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 | 2023-08-16 | 2023-09-20 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-08-16 | 2023-09-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-16 | 2023-09-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-04 | 2023-07-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-08 | 2023-07-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-04 | 2023-06-14 | 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 | 2023-05-04 | 2023-06-14 | 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 | 2023-05-04 | 2023-06-14 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-05-04 | 2023-06-14 | N |
| Respond appropriately to all alleged violations. | Health | 2023-05-04 | 2023-06-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-04 | 2023-06-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-04 | 2023-06-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-04 | 2023-06-14 | 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 | 2023-05-04 | 2023-06-14 | N |
| Dispose of garbage and refuse properly. | Health | 2023-05-04 | 2023-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-04 | 2023-06-14 | N |
| Keep all essential equipment working safely. | Health | 2023-05-04 | 2023-06-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-04 | 2023-06-14 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-01 | 2023-06-14 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-05-01 | 2023-06-14 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-05-01 | 2023-06-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-01 | 2023-06-14 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-05-01 | 2023-06-14 | 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 | 2023-05-01 | 2023-06-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-01 | 2023-06-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-01 | 2023-06-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-01 | 2023-06-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-01 | 2023-06-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-01 | 2023-06-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-01 | 2023-06-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-01 | 2023-06-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-01 | 2023-06-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-01 | 2023-06-14 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-05-01 | 2023-06-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-01 | 2023-06-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-01 | 2023-06-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-01 | 2023-06-14 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-06-08 | 2023-06-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-23 | 2023-02-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-23 | 2023-02-23 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-01-04 | 2023-01-31 | 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 | 2023-01-04 | 2023-01-31 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-01-04 | 2023-01-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-13 | 2023-01-16 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-13 | 2023-01-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-04 | 2022-12-26 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-10-19 | 2022-11-21 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-07-28 | 2022-09-12 | 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 | 2022-07-28 | 2022-09-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-28 | 2022-09-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-07-28 | 2022-09-12 | 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 | 2022-07-08 | 2022-08-12 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-07-08 | 2022-08-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-08 | 2022-08-12 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-07-08 | 2022-08-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-08 | 2022-08-12 | 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 | 2022-07-08 | 2022-08-12 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-08 | 2022-08-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-08 | 2022-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-08 | 2022-08-12 | N |
| Keep all essential equipment working safely. | Health | 2022-07-08 | 2022-08-12 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-07-08 | 2022-08-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-07 | 2022-07-07 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-05-24 | 2022-06-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-15 | 2022-04-06 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-03-08 | 2022-03-28 | 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 | 2022-01-25 | 2022-03-01 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-25 | 2022-03-01 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-01-25 | 2022-03-01 | Y |
