Deficiency Records for Care Pavilion Nursing and Rehabilitation Center
Updated as of November 01, 2022
This is not the most recent data for Care Pavilion Nursing and Rehabilitation Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| 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 |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Establish methods for sharing information. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Meet other general requirements. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-05-20 | 2021-07-30 | 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 | 2021-05-20 | 2021-07-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-20 | 2021-07-30 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-05-12 | 2021-07-07 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-05-12 | 2021-07-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-12 | 2021-07-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-12 | 2021-07-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-12 | 2021-07-07 | 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 | 2021-05-12 | 2021-07-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-05-12 | 2021-07-07 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-05-12 | 2021-07-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-12 | 2021-07-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-12 | 2021-07-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-12 | 2021-07-07 | N |
| Keep all essential equipment working safely. | Health | 2021-05-12 | 2021-07-07 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-02-11 | 2021-02-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-02-11 | 2021-02-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-02-11 | 2021-02-25 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-02-11 | 2021-02-25 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-02-11 | 2021-02-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-11-05 | 2020-12-11 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2020-11-05 | 2020-12-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-10-07 | 2020-11-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-07 | 2020-11-07 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2020-10-07 | 2020-11-07 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-04-25 | 2019-07-17 | 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 | 2019-04-25 | 2019-07-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-30 | 2019-06-29 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-04-30 | 2019-06-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-30 | 2019-06-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-04-30 | 2019-06-29 | 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 | 2019-04-30 | 2019-06-24 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-04-25 | 2019-06-24 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-04-25 | 2019-06-24 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-04-25 | 2019-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-25 | 2019-06-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-25 | 2019-06-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-04-25 | 2019-06-24 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2019-04-25 | 2019-06-24 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-04-25 | 2019-06-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-25 | 2019-06-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-25 | 2019-06-24 | N |
