Deficiency Records for Monarch Pavilion Rehabilitation Suites
Updated as of March 01, 2024
A list of the most recent deficiencies for Monarch Pavilion Rehabilitation Suites. 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? |
---|---|---|---|---|
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-19 | 2023-10-20 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-19 | 2023-10-20 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-18 | 2023-10-19 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-18 | 2023-10-19 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-18 | 2023-10-19 | N |
Provide and implement an infection prevention and control program. | Health | 2023-10-18 | 2023-10-19 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-18 | 2023-10-19 | Y |
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 | 2023-10-18 | 2023-10-19 | Y |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-18 | 2023-10-19 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-18 | 2023-10-19 | Y |
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 | 2023-10-18 | 2023-10-19 | Y |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-10-18 | 2023-10-19 | Y |
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 | 2023-09-01 | 2023-09-02 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-23 | 2023-08-24 | Y |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-23 | 2023-08-24 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-03 | 2023-08-18 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-03 | 2023-08-18 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-20 | 2023-07-21 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-15 | 2023-06-16 | Y |
Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-06-15 | 2023-06-16 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-15 | 2023-06-16 | Y |
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 | 2023-06-15 | 2023-06-16 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-28 | 2022-09-29 | Y |
Use approved construction type or materials. | Fire Safety | 2022-09-01 | 2022-09-21 | N |
Keep residents' personal and medical records private and confidential. | Health | 2022-09-01 | 2022-09-02 | 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 | 2022-09-01 | 2022-09-02 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-01 | 2022-09-02 | 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 | 2022-09-01 | 2022-09-02 | N |
Provide and implement an infection prevention and control program. | Health | 2022-09-01 | 2022-09-02 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-01 | 2022-09-02 | N |
Install proper backup exit lighting. | Fire Safety | 2022-09-01 | 2022-09-02 | 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 | 2022-09-01 | 2022-09-02 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-01 | 2022-09-02 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-05 | 2022-01-26 | Y |
Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-01-05 | 2022-01-26 | 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 | 2021-10-06 | 2021-10-29 | Y |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-07-15 | 2021-08-20 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-15 | 2021-08-13 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-15 | 2021-08-13 | Y |
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 | 2021-07-15 | 2021-08-13 | N |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-07-15 | 2021-08-13 | 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 | 2021-07-15 | 2021-08-06 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-15 | 2021-08-06 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-15 | 2021-08-06 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-15 | 2021-08-06 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-03 | 2021-06-25 | Y |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-03 | 2021-06-25 | Y |
Have policies on smoking. | Health | 2021-06-03 | 2021-06-25 | Y |