Facility profile · CCN 145939
Pavilion Of South Shore
51 federal citations on record , including 1 at the Immediate Jeopardy level, and 3 federal enforcement actions totaling $105,248.
Record summary
Federal record · Q1 202651
Total citations
38
Last 3 years
4
Actual harm+
3
Federal penalties
$105,248
Total fines
3
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
51 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| May 8, 2025 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Complaint |
| Feb 24, 2025 | F610 | Respond appropriately to all alleged violations. | D | Complaint |
| Feb 24, 2025 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Feb 7, 2025 | F887 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | D | Standard |
| Feb 7, 2025 | F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Standard |
| Feb 7, 2025 | F880 | Provide and implement an infection prevention and control program. | E | Standard |
| Feb 7, 2025 | F814 | Dispose of garbage and refuse properly. | F | Standard |
| Feb 7, 2025 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard |
| Feb 7, 2025 | F700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | D | Standard |
| Feb 7, 2025 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| Feb 7, 2025 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| Feb 7, 2025 | F688 | 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. | D | Standard |
| Feb 7, 2025 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| Feb 7, 2025 | F578 | 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. | D | Standard |
| Feb 7, 2025 | F558 | Reasonably accommodate the needs and preferences of each resident. | D | Standard |
| Dec 5, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint |
| Dec 5, 2024 | F558 | Reasonably accommodate the needs and preferences of each resident. | D | Complaint |
| Sep 30, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | Complaint |
| Sep 30, 2024 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | Complaint |
| Jun 13, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint |
| Apr 19, 2024 | F880 | Provide and implement an infection prevention and control program. | F | Standard |
| Apr 19, 2024 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard |
| Apr 19, 2024 | F761 | 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. | E | Standard |
| Apr 19, 2024 | F758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D | Standard |
| Apr 19, 2024 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| Apr 19, 2024 | F692 | Provide enough food/fluids to maintain a resident's health. | G | Standard |
| Apr 19, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| Apr 19, 2024 | F688 | 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. | D | Standard |
| Apr 19, 2024 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard |
| Apr 19, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E | Standard |
| Apr 19, 2024 | F558 | Reasonably accommodate the needs and preferences of each resident. | D | Standard |
| Apr 19, 2024 | F554 | Allow residents to self-administer drugs if determined clinically appropriate. | D | Standard |
| Apr 19, 2024 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E | Standard |
| Jan 12, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | Complaint |
| Jan 12, 2024 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint |
| Jan 12, 2024 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Nov 16, 2023 | F697 | Provide safe, appropriate pain management for a resident who requires such services. | D | Complaint |
| Nov 16, 2023 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint |
| Mar 15, 2023 | F924 | Put firmly secured handrails on each side of hallways. | E | Standard |
| Mar 15, 2023 | F919 | Make sure that a working call system is available in each resident's bathroom and bathing area. | D | Standard |
| Mar 15, 2023 | F888 | Ensure staff are vaccinated for COVID-19 | F | Standard |
| Mar 15, 2023 | F880 | Provide and implement an infection prevention and control program. | E | Standard |
| Mar 15, 2023 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Standard |
| Mar 15, 2023 | F761 | 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. | E | Standard |
| Mar 15, 2023 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Standard |
| Mar 15, 2023 | F692 | Provide enough food/fluids to maintain a resident's health. | D | Standard |
| Mar 15, 2023 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard |
| Mar 15, 2023 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | Standard |
| Mar 15, 2023 | F584 | 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. | E | Standard |
| Mar 15, 2023 | F567 | Honor the resident's right to manage his or her financial affairs. | D | Standard |
| Mar 15, 2023 | F558 | Reasonably accommodate the needs and preferences of each resident. | D | Standard |
Federal enforcement history
Federal regulators have imposed 3 enforcement actions against this facility, including 3 civil money penalties totaling $105,248 .
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| Sep 30, 2024 | Fine | $69,439 | — |
| Apr 19, 2024 | Fine | $22,122 | — |
| Jan 12, 2024 | Fine | $13,687 | — |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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