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Deficiency Records for Care Pavilion Nursing and Rehabilitation Center

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.

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?
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-05-31 2024-07-02 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2024-05-31 2024-07-02 N
Ensure each resident receives an accurate assessment. Health 2024-05-31 2024-07-02 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-05-31 2024-07-02 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-05-31 2024-07-02 N
Have enough backup water supply for essential areas of the nursing home. Health 2024-05-31 2024-07-02 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-03-26 2024-04-23 Y
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2024-03-26 2024-04-23 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-02-22 2024-02-28 Y
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 2023-07-07 2023-07-14 Y
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2023-07-07 2023-07-14 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
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

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