Inspection visit
Inspection
Citations
22 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0007GeneralS&S Fpotential for harm
Address patient/client population and determine types of services needed.
- 0024GeneralS&S Fpotential for harm
Establish policies and procedures for volunteers.
- 0025GeneralS&S Fpotential for harm
Create arrangements with other facilities to receive patients.
- 0030GeneralS&S Fpotential for harm
List the names and contact information of those in the facility.
- 0031GeneralS&S Fpotential for harm
Provide emergency officials' contact information.
- 0034GeneralS&S Fpotential for harm
Provide a means of sharing information on occupancy/needs.
- 0035GeneralS&S Fpotential for harm
Provide family notifications of emergency plan.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0225GeneralS&S Fpotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F911 - Accommodate no more than four residents
Meet requirements for the installation and maintenance of electrical systems.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the March 23, 2023 survey of THE PAVILION AT CRESCENT LAKE?
This was a inspection survey of THE PAVILION AT CRESCENT LAKE on March 23, 2023. The surveyor cited 22 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE PAVILION AT CRESCENT LAKE on March 23, 2023?
Yes, 22 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives an accurate assessment."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.