A list of the most recent deficiencies for The Pavilion at Creekwood. 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-11-21 | 2023-12-18 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-12 | 2023-12-13 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-11-21 | 2023-11-22 | 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 | 2023-03-21 | 2023-03-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-16 | 2023-03-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-16 | 2023-02-21 | Y |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-11-30 | 2023-01-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-30 | 2023-01-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-30 | 2022-12-28 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-11-30 | 2022-12-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-30 | 2022-12-06 | 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 | 2022-11-30 | 2022-12-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-30 | 2022-12-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-30 | 2022-12-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-30 | 2022-12-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-03 | 2022-10-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-03 | 2022-10-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-03 | 2022-10-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-28 | 2022-06-30 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-06-28 | 2022-06-30 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-29 | 2022-05-02 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-01-18 | 2022-01-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-21 | 2022-01-20 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-09-02 | 2021-09-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-02 | 2021-09-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-02 | 2021-09-03 | N |
| 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 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-19 | 2019-10-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-24 | 2019-09-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-09-24 | 2019-09-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-24 | 2019-09-26 | N |
| Ensure that gas containers are correctly designed and tested, and in locations that are labeled. | Fire Safety | 2019-09-24 | 2019-09-25 | N |
