🔎 Pavilion On Main Street The
Inspection Results
Inspection Overview
Pavilion On Main Street The has been cited for a total of 72 deficiencies since we began saving each survey.
In Illinois, the average facility has **50.07 deficiencies** in our database. This profile shows the longer-term view.
Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.
Understanding Deficiency Severity (A-L Scale)
The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**
| Severity (Harm) | Scope (Widespread?) | Code Range |
|---|---|---|
| No Actual Harm | Isolated to Pattern | A - C |
| No Actual Harm | Widespread | D - F |
| **Actual Harm** | Isolated | G |
| **Actual Harm** | Pattern | H |
| **Actual Harm** | Widespread | I |
| **Immediate Jeopardy** | Isolated | J |
| **Immediate Jeopardy** | Pattern | K |
| **Immediate Jeopardy** | Widespread | L |
Detailed Deficiency List (Most Recent First)
Scope/Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: D
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.
Scope/Severity: D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity: D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Scope/Severity: G
Provide safe, appropriate pain management for a resident who requires such services.
Scope/Severity: F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Scope/Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
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.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
Ensure that residents are free from significant medication errors.
Scope/Severity: D
Keep residents' personal and medical records private and confidential.
Scope/Severity: J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Scope/Severity: D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Scope/Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Scope/Severity: D
Respond appropriately to all alleged violations.
Scope/Severity: F
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity: D
Provide enough food/fluids to maintain a resident's health.
Scope/Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Scope/Severity: D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Scope/Severity: G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: G
Provide safe, appropriate pain management for a resident who requires such services.
Scope/Severity: D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Scope/Severity: D
Ensure that residents are free from significant medication errors.
Scope/Severity: E
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.
Scope/Severity: F
Provide and implement an infection prevention and control program.
Scope/Severity: F
Report COVID19 data to residents and families.
Scope/Severity: D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Scope/Severity: F
Perform COVID19 testing on residents and staff.
Scope/Severity: F
Provide and implement an infection prevention and control program.
Scope/Severity: F
Provide and implement an infection prevention and control program.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: F
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.
Scope/Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Scope/Severity: E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Scope/Severity: D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity: D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Scope/Severity: D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Scope/Severity: D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity: D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
Ensure that residents are free from significant medication errors.
Scope/Severity: D
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Scope/Severity: E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: D
Provide and implement an infection prevention and control program.
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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**