Pavilions at Forrestal , the

Total Number of Beds: 180	Percent of Occupied Beds: 76%
Total Number of Residents: 137	Located Within a Hospital: No
Type of Ownership: For profit - Corporation	Multiple Nursing Homes by Same Owner: No
Councils the Nursing Home Participates in: Resident	Medicare/Medicaid: Participating in Medicare and Medicaid
* Details Last Reported on: 07/15/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.59

Number of LPN/LVN Hours per Nursing Home Resident per Day: 1.29

Number of CNA Hours per Nursing Home Resident per Day: 2.62

Number of Staff Hours per Nursing Home Resident per Day: 4.5

Nursing Home Resident Information**:

Percent of Low-Risk Residents Who Have Pressure Sores: 7%
Percent of Short-Stay Residents With Pressure Sores: 34%
Percent of High-Risk Residents Who Have Pressure Sores: 20%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain: 14%
Percent of Residents Who Have Moderate to Severe Pain: 3%
Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse: 43%
Percent of Residents Who Spend Most of Their Time in Bed or in a Chair: 2%
Percent of Residents Whose Need for Help With Daily Activities Has Increased: 35%
Percent of Residents Who are More Depressed or Anxious: 11%
Percent of Short-Stay Residents With Delirium: 1%
Percent of Residents Who Were Physically Restrained: 0%
Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder: 51%
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 5%
Percent of Residents With a Urinary Tract Infection: 14%
** Details Last Reported on: 7/15/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2001-07-31	2001-10-05	Resident Rights Deficiencies	Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.	Widespread	Potential for minimal harm
2001-07-31	2001-10-05	Resident Rights Deficiencies	Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Pattern	Potential for minimal harm
2001-07-31	2001-10-05	Resident Rights Deficiencies	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
2001-07-31	2001-10-05	Mistreatment Deficiencies	Protect residents from mistreatment, neglect, and/or theft of personal property.	Widespread	Immediate jeopardy to resident health or safety
2001-07-31	0000-00-00	Resident Rights Deficiencies	Provide care in a way that keeps or builds each resident's dignity and self respect.	Widespread	Immediate jeopardy to resident health or safety
2001-07-31	2001-10-05	Resident Rights Deficiencies	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
2001-07-31	2001-10-05	Quality Care Deficiencies	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
2001-07-31	2001-08-16	Quality Care Deficiencies	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Widespread	Immediate jeopardy to resident health or safety
2001-07-31	2001-10-05	Environmental Deficiencies	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
2001-07-31	0000-00-00	Resident Assessment Deficiencies	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Widespread	Immediate jeopardy to resident health or safety
2001-07-31	2001-10-05	Resident Assessment Deficiencies	Do an assessment of the resident every year.	Isolated	Minimal harm or potential for actual harm
2001-07-31	2001-10-05	Resident Assessment Deficiencies	Check and update (if needed) each resident's assessment every 3 months.	Isolated	Minimal harm or potential for actual harm
2001-07-31	2001-10-05	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Widespread	Immediate jeopardy to resident health or safety
2001-07-31	2001-10-05	Resident Assessment Deficiencies	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Pattern	Minimal harm or potential for actual harm
2001-07-31	0000-00-00	Quality Care Deficiencies	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
2001-07-31	0000-00-00	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
2001-07-31	0000-00-00	Quality Care Deficiencies	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Pattern	Minimal harm or potential for actual harm
2001-07-31	2001-10-05	Quality Care Deficiencies	Make sure that residents with loss of bladder control receive treatment or service to prevent infections and help get normal bladder control.	Isolated	Actual harm
2001-07-31	2001-10-05	Quality Care Deficiencies	Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Isolated	Minimal harm or potential for actual harm
2001-07-31	2001-08-16	Environmental Deficiencies	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Immediate jeopardy to resident health or safety
2001-07-31	2001-10-05	Quality Care Deficiencies	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Actual harm
2001-07-31	2001-10-05	Pharmacy Service Deficiencies	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
2001-07-31	2001-10-05	Pharmacy Service Deficiencies	Make sure that residents who have not taken antipsychotic drugs are not given these drugs, unless they are used to treat a problem that is diagnosed and noted in the medical record.	Pattern	Minimal harm or potential for actual harm
2001-07-31	2001-08-16	Quality Care Deficiencies	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Widespread	Immediate jeopardy to resident health or safety
2001-07-31	2001-10-05	Nutrition and Dietary Deficiencies	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Widespread	Minimal harm or potential for actual harm
2001-07-31	2001-10-05	Nutrition and Dietary Deficiencies	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Widespread	Minimal harm or potential for actual harm
2001-07-31	2001-10-05	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
2001-07-31	2001-10-05	Pharmacy Service Deficiencies	Make sure that the pharmacist reports anything unusual to the doctor on duty and the director of nursing.	Isolated	Minimal harm or potential for actual harm
2001-07-31	2001-10-05	Pharmacy Service Deficiencies	Keep drugs and other similar products locked safely and properly stored.	Widespread	Minimal harm or potential for actual harm
2001-07-31	2001-10-05	Environmental Deficiencies	Make sure that staff members wash their hands when needed.	Isolated	Minimal harm or potential for actual harm
2001-07-31	2001-10-05	Environmental Deficiencies	Move, clean and store sheets, towels and other linens in a way that prevents the spread of infection.	Widespread	Minimal harm or potential for actual harm
2001-07-31	2001-08-16	Environmental Deficiencies	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.	Widespread	Immediate jeopardy to resident health or safety
2001-07-31	2001-10-05	Environmental Deficiencies	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Pattern	Minimal harm or potential for actual harm
2001-07-31	2001-10-05	Environmental Deficiencies	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Pattern	Minimal harm or potential for actual harm
2001-07-31	2001-08-16	Administration Deficiencies	Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Immediate jeopardy to resident health or safety
2001-07-31	2001-10-05	Administration Deficiencies	Hire nurse aides who have completed required training and shown that they are skilled.	Pattern	Minimal harm or potential for actual harm
2001-07-31	2001-10-05	Administration Deficiencies	Get proof that a nurse aide has the training and skills that the State requires.	Pattern	Minimal harm or potential for actual harm
2001-07-31	2001-10-05	Administration Deficiencies	1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Widespread	Minimal harm or potential for actual harm
2001-07-31	2001-10-05	Administration Deficiencies	Get services outside the nursing home that meet professional standards.	Pattern	Minimal harm or potential for actual harm
2001-07-31	2001-08-16	Administration Deficiencies	Train all employees on what to do in an emergency.	Widespread	Minimal harm or potential for actual harm
2001-07-31	2001-10-05	Administration Deficiencies	Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
2001-07-31	2001-10-05	Administration Deficiencies	Hold committee meetings every 3 months to review and ensure quality in the nursing home.	Widespread	Minimal harm or potential for actual harm
2002-06-14	2002-07-30	Resident Rights Deficiencies	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
2002-06-14	2002-07-30	Resident Assessment Deficiencies	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
2002-06-14	2002-07-30	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
2002-06-14	2002-07-30	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
2002-06-14	2002-07-30	Quality Care Deficiencies	Make sure that each residents' abilities to take care of themselves does not lessen, unless a change cannot be avoided.	Isolated	Minimal harm or potential for actual harm
2002-06-14	2002-07-30	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
2002-06-14	2002-07-30	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Isolated	Minimal harm or potential for actual harm
2002-06-14	2002-07-30	Quality Care Deficiencies	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
2002-06-14	2002-07-30	Nutrition and Dietary Deficiencies	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
2002-06-14	2002-07-30	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
2002-06-14	2002-07-30	Pharmacy Service Deficiencies	Make sure that the pharmacist reports anything unusual to the doctor on duty and the director of nursing.	Isolated	Minimal harm or potential for actual harm
2002-06-14	2002-07-30	Environmental Deficiencies	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Minimal harm or potential for actual harm
2003-07-15	2003-08-28	Mistreatment Deficiencies	Protect each resident from all abuse, physical punishment, and being separated from others.	Isolated	Minimal harm or potential for actual harm
2003-07-15	2003-08-28	Mistreatment Deficiencies	1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
2003-07-15	2003-08-28	Quality Care Deficiencies	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
2003-07-15	2003-08-28	Quality Care Deficiencies	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
2003-07-15	2003-08-28	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Isolated	Minimal harm or potential for actual harm
2003-07-15	2003-08-28	Quality Care Deficiencies	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm

*** All violations listed are based on federal government records.