Deficiency Records for Monarch Pavilion Rehabilitation Suites
Updated as of January 01, 2022
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 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 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-02-04 | 2021-01-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-11-10 | 2020-12-07 | Y |
| Use approved construction type or materials. | Fire Safety | 2020-10-15 | 2020-11-27 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-10-15 | 2020-11-27 | 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 | 2020-10-15 | 2020-11-27 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-10-15 | 2020-11-27 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-10-15 | 2020-11-27 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2020-08-21 | 2020-09-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-08-21 | 2020-09-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-07-24 | 2020-08-13 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-07-24 | 2020-08-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-04-20 | 2020-05-10 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-02-05 | 2020-03-17 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-05 | 2020-03-17 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-17 | 2019-10-17 | 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 | 2019-09-17 | 2019-10-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-17 | 2019-10-17 | 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 | 2019-09-17 | 2019-10-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-17 | 2019-10-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-09-19 | 2019-10-15 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-09-19 | 2019-10-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-19 | 2019-10-15 | Y |
| 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 and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-09-21 | 2018-10-18 | N |
| Respond appropriately to all alleged violations. | Health | 2018-09-21 | 2018-10-18 | 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 |
| 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 | 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 |
| 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 |
