Facility profile · CCN 366158
The Pavilion Rehabilitation And Nursing Center
64 federal citations on record , including 2 at the Immediate Jeopardy level.
Record summary
Federal record · Q1 202664
Total citations
24
Last 3 years
2
Actual harm+
0
Federal penalties
$0
Total fines
2
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
64 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Feb 19, 2025 | F744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | D | Complaint |
| Feb 19, 2025 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | Complaint |
| Jan 9, 2025 | F921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | F | Standard |
| Jan 9, 2025 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Standard |
| Jan 9, 2025 | 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. | D | Standard |
| Jan 9, 2025 | F760 | Ensure that residents are free from significant medication errors. | D | Standard |
| Jan 9, 2025 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Standard |
| Jan 9, 2025 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard |
| Jan 9, 2025 | F645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | Standard |
| Jan 9, 2025 | F636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | D | Standard |
| Jan 9, 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 |
| Nov 26, 2024 | F921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | F | Complaint |
| Aug 19, 2024 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint |
| Jun 26, 2024 | F908 | Keep all essential equipment working safely. | F | Complaint |
| Jun 26, 2024 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Complaint |
| Jun 26, 2024 | F802 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | F | Complaint |
| Jun 26, 2024 | 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 | Complaint |
| Jun 26, 2024 | F573 | Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | D | Complaint |
| May 15, 2024 | F921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | F | Complaint |
| May 15, 2024 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Complaint |
| May 15, 2024 | F730 | Observe each nurse aide's job performance and give regular training. | C | Complaint |
| Mar 22, 2024 | F759 | Ensure medication error rates are not 5 percent or greater. | D | Complaint |
| Mar 22, 2024 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Complaint |
| Mar 22, 2024 | 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. | D | Complaint |
| Mar 21, 2023 | F921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | F | Complaint |
| Mar 21, 2023 | F880 | Provide and implement an infection prevention and control program. | C | Complaint |
| Mar 21, 2023 | F867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F | Complaint |
| Mar 21, 2023 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | Complaint |
| Mar 21, 2023 | F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | F | Complaint |
| Mar 21, 2023 | F801 | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | F | Complaint |
| Mar 21, 2023 | F679 | Provide activities to meet all resident's needs. | D | Complaint |
| Mar 21, 2023 | F610 | Respond appropriately to all alleged violations. | E | Complaint |
| Mar 21, 2023 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Mar 21, 2023 | F607 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | F | Complaint |
| Mar 21, 2023 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | E | Complaint |
| Mar 21, 2023 | F577 | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | C | Complaint |
| Mar 21, 2023 | F565 | Honor the resident's right to organize and participate in resident/family groups in the facility. | E | Complaint |
| Oct 24, 2022 | F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Standard |
| Oct 24, 2022 | F760 | Ensure that residents are free from significant medication errors. | K | Standard |
| Oct 24, 2022 | F759 | Ensure medication error rates are not 5 percent or greater. | D | Standard |
| Oct 24, 2022 | 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 |
| Oct 24, 2022 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Standard |
| Oct 24, 2022 | F710 | Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | D | Standard |
| Oct 24, 2022 | F690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Standard |
| Oct 24, 2022 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard |
| Oct 24, 2022 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| Oct 24, 2022 | F679 | Provide activities to meet all resident's needs. | E | Standard |
| Oct 24, 2022 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Standard |
| Oct 24, 2022 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard |
| Oct 24, 2022 | F655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | Standard |
| Oct 24, 2022 | F625 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | D | Standard |
| Oct 24, 2022 | F623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D | Standard |
| Oct 24, 2022 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | J | Standard |
| Oct 24, 2022 | 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 |
| Oct 24, 2022 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Standard |
| Oct 31, 2019 | F926 | Have policies on smoking. | F | Standard |
| Oct 31, 2019 | F921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | E | Standard |
| Oct 31, 2019 | F919 | Make sure that a working call system is available in each resident's bathroom and bathing area. | E | Standard |
| Oct 31, 2019 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Standard |
| Oct 31, 2019 | F759 | Ensure medication error rates are not 5 percent or greater. | D | Standard |
| Oct 31, 2019 | F679 | Provide activities to meet all resident's needs. | D | Standard |
| Oct 31, 2019 | 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 |
| Oct 31, 2019 | 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 |
| Oct 31, 2019 | F558 | Reasonably accommodate the needs and preferences of each resident. | E | Standard |
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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