Pavilion at Brandon Wilde

In the surveyor’s words

From the most serious findings on record at Pavilion at Brandon Wilde, in the surveyor’s own words.

• Actual harm, isolatedF656Jan 27, 2022

  Based on observations, interviews, and record review, the facility failed to follow the care plan related to transfer for one Resident (R) R#17 resulting in actual harm due to bilateral fractured femurs. The resident sample was 24. Findings include: Record review revealed that R#17 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued record review revealed the resident was dishcharged from the facility to an acute care hospital on 9/10/21 for bilateral femur fractures requiring surgical interventions and returned to the facility on [DATE]. […]

• Actual harm, isolatedF689Jan 27, 2022

  Based on record review and staff interviews, the facility failed to ensure that the appropriate mechanical lift was utilized to ensure a safe transfer for one resident (R) #17 who required transfer with a Hoyer lift by two persons. Actual harm was identified when R#17 began to exhibit signs and symptoms of pain and her x-ray results showed bilateral femoral fractures (hip fractures) requiring surgical intervention. Sample size was 24 residents. Findings include: Record review revealed that R#17 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease, dysphagia, [CONDITION(S)], peripheral vascular disease (PVD) and bilateral knee replacement. […]

• No harm, potential for more than minimal, patternF585Apr 17, 2026

  Based on interviews, record review, and policy review, the facility failed to ensure grievances were promptly resolved for five residents (Resident (R) 9) R23, R35, R50, and R61 of 22 sample residents. Specifically, the facility failed to date, summarize findings, and document corrective action taken as a result of the grievance. This failure had the potential to cause further grievances to be unresolved for residents throughout the facility. 1.Review of R23's ) revealed a quarterly Minimum Data Set (MDS)'' assessment, located under the ''MDS'' tab electronic medical record (EMR), with an Assessment Reference Date (ARD) of 03/13/26 revealed R23's admission date was 08/26/25. R23 had a diagnosis that included kidney insufficiency. […]

• No harm, potential for more than minimal, patternF607Apr 17, 2026

  Based on record review, interviews, and facility policy, the facility failed to ensure a Georgia Criminal History Check System (GCHEXS) fingerprint background check was completed prior to date of hire for one of seven new hire employees and reference checks were completed for seven of seven new hire employees. The deficient practice could result in a staff with an unknown criminal background having access to residents. 1.Review of employee records for the Administrator revealed he was hired on 12/01/25. The required GCHEXS fingerprint background check was completed on 12/02/25.During an interview on 04/17/26 at 3:42 PM, the Human Resources Director (HRD) stated GCHEXS background checks are completed for all employees except nurses and are required to be completed prior to the start date. […]

• No harm, potential for more than minimal, patternF554Sep 17, 2023

  46691 Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Self-Administration of Drugs, the facility failed to assess six of 28 residents (R) R#33, R#53, R#55, R#54, R#20, and R#2 reviewed for the ability to self-administer medications prior to leaving medications at the bedside. The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents. Findings include: Review of the facility policy titled Self-Administration of Drugs effective date 12/22/2014 revealed: Intent statement: It is the intent of this facility to permit residents to self-administer their drugs and medications unless such practice for the resident is deemed unsafe. 1. […]