Care Pavilion Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Care Pavilion Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 18, 2025

  Based on review of facility policy, facility documentation, clinical records, and staff interviews, it was determined the facility failed to protect Resident R271 with severe cognitive impairment from unwanted/non-consensual sexual contact by Resident R137 who had a history of sexually inappropriate behavior, including an unsolicited sexual contact with Resident 208 on January 31, 2025. This failure resulted in an Immediate Jeopardy situation when Resident R137 was found pinning down and performing oral sex on Resident R271. (Resident R137 and Resident R271) Findings Include: Review of facility policy titled Abuse reviewed December 13, 2024, revealed sexual abuse is defined as non-consensual sexual contact of any type with a resident. […]

• Immediate jeopardy, isolatedF600Jan 19, 2024

  Based on review of facility policies, facility documentation, review of clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from verbal abuse for one of 36 residents reviewed which resulted in an Immediate Jeopardy Situation (Resident R464). Findings include: The facility's Abuse Policy dated November 28, 2016, indicates: verbal abuse is defined as the user of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident, or within their hearing distance, regarding less of their age, ability to comprehend, or disability. […]

• Immediate jeopardy, isolatedF689Sep 20, 2023

  Based on observations, review of clinical records, review of facility policies, review of documentation and interviews with residents and staff, it was determined that the facility failed to adequately supervise a resident who was assessed to be at risk for elopement for one of eight residents reviewed, resulting in Resident R1 exiting the secure dementia unit, eloping from the facility, and missing for over 24 hours. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF689Jun 8, 2023

  Based on review of clinical records, review of a facility reported incident, review of facility policies, review of facility documentation and interviews with staff, it was determined that the facility failed to provide appropriate supervision for one of eight residents reviewed (Resident R1) which resulted in Resident R1 eloping from the facility during a smoking break at 2:30 a.m. This failure placed Resident R1 at high risk for injury and resulted in an Immediate Jeopardy situation. Findings include: Review of facility policy titled, Elopement revised October 24, 2022, revealed it is the policy of the facility to provide a safe and secure environment for all residents. The purpose of the policy is to assure the safety and security of all residents. […]

• Immediate jeopardy, isolatedF689Jan 4, 2023

  Based on observations, clinical record review, review of facility policies and documentation and interviews with residents and staff, it was determined that the facility failed to adequately supervise a resident who was assessed to be at risk for elopement for one of eight residents reviewed, resulting in Resident R1 exiting the secure dementia unit, eloping from the facility and missing for over 24 hours. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. […]