Deficiency Records for Monarch Pavilion Rehabilitation Suites
Updated as of July 01, 2019
This is not the most recent data for Monarch Pavilion Rehabilitation Suites. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-15 | 2019-06-07 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-19 | 2018-10-31 | 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 | 2018-09-21 | 2018-10-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-21 | 2018-10-18 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-09-21 | 2018-10-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-21 | 2018-10-18 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2018-09-21 | 2018-10-18 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-09-21 | 2018-10-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-09-21 | 2018-10-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-21 | 2018-10-18 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2018-09-19 | 2018-10-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-09-19 | 2018-09-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-09-19 | 2018-09-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-09-19 | 2018-09-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-09-19 | 2018-09-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-09-19 | 2018-09-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-19 | 2018-09-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-09-19 | 2018-09-21 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-09-19 | 2018-09-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-09-19 | 2018-09-19 | 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 | 2018-09-19 | 2018-09-19 | 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 | 2018-05-08 | 2018-05-11 | Y |
| Install proper backup exit lighting. | Fire Safety | 2017-09-27 | 2017-10-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-09-27 | 2017-10-27 | N |
| Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. | Health | 2017-09-27 | 2017-10-27 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-27 | 2017-10-27 | N |
| Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. | Health | 2017-09-27 | 2017-10-27 | N |
| Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2017-09-27 | 2017-10-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-09-27 | 2017-10-27 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-09-19 | 2017-09-27 | Y |
| Keep clinical record information safe. | Health | 2017-09-19 | 2017-09-27 | Y |
| Properly protected cooking facilities. | Fire Safety | 2016-10-04 | 2016-11-11 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2016-10-04 | 2016-11-11 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-10-05 | 2016-11-11 | Y |
