PAVILION, THE CPC (LEBANON, TN) Detailed Nursing Home Profile

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

This Nursing Home:	8.2%
State:	14.8%

Percent of long-stay residents who self-report moderate to severe pain

Here:	7.7%
Tennessee:	9.9%

Percent of long-stay high-risk residents with pressure ulcers

Here:	2.6%
Tennessee:	5.9%

Percent of long-stay residents who lose too much weight

This Nursing Home:	13.2%
State:	8.2%

Percent of long-stay residents who have depressive symptoms

This Nursing Home:	7.5%
Tennessee:	3.7%

Percent of long-stay residents experiencing one or more falls with major injury

This Nursing Home:	3.8%
Tennessee:	3.5%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Nursing Home:	100.0%
State:	95.8%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	100.0%
Tennessee:	92.9%

Percent of short-stay residents with Pressure ulcers that are new or worsened

Here:	3.8%
State:	1.5%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	100.0%
State:	86.6%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	97.7%
Tennessee:	83.0%

Percent of short-stay residents who newly received an antipsychotic medication

Here:	5.7%
Tennessee:	3.6%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	28.8%
Tennessee:	29.9%

Complaint Deficiency

Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly maintained smoke detectors
- Harm: Minimal harm or potential for actual harm
- Scope: Some
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Portable fire extinguishers
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Proper facilities for the use and storage of combustible liquids
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Portable fire extinguishers
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.480
State:	0.580

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

This Nursing Home:	1.010
State:	0.997

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	1.490
State:	1.565

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.100
State:	0.081

Number Therapy Hours Per Resident Per Day

This Nursing Home:	0.100
Tennessee:	0.085

PAVILION, THE CPC - LEBANON, TN

Quality Measures

Complaint Deficiency

Staff Information

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