Pavilion for Health Care, The

In the surveyor’s words

From the most serious findings on record at Pavilion for Health Care, The, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Apr 7, 2021

  Based on observations, staff interviews, and facility document review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The findings include: A tour of the kitchen began at 11:51am on 4/5/2021. A microwave and juice machine fountain, both located next to the entrance of the kitchen, were not clean. Dried food particles and miscellaneous stains were observed on the door, sides, base, and internal hood of the microwave, above the area where food is placed during heating. Thick, gel-like substances were splattered along the panel of the juice fountain above the spouts where the juice is dispensed. […]

• No harm, potential for more than minimal, isolatedF842Jun 20, 2024

  Based on observation, record review, staff interview, and policy and procedure review, the facility failed to maintain accurately documented medical records for one (Resident #13) of one resident reviewed for non-pressure related skin conditions. The findings include: An observation was made of Resident #13 on 6/18/24 at 10:00 AM. He had a large, tan colored, adhesive dressing on his left leg, dated 6/14/24. A review of the electronic medical record (EMR) revealed a physician's order dated 6/12/24, instructing nursing staff to cleanse the left leg below the knee skin tear with normal saline, apply antibiotic ointment, and cover with a Band-Aid once a day, every other day until healed. […]

• No harm, potential for more than minimal, isolatedF759Sep 15, 2022

  Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less, based on three errors out of 31 opportunities for error, resulting in an error rate of 9.68%. This involved three (Residents #31 and #6 & #13) of five residents observed during medication administration, from a total sample of 18 residents. The findings include: During a medication administration observation for Resident #31 on 09/14/22 at 9:37 a.m., Licensed Practical Nurse (LPN) A obtained [MEDICATION(S)] 10 milligrams (mg) and Losartan 100 mg. Both medications had special instructions to hold the medications if the resident's blood pressure (BP) was less than 120/80. […]

• No harm, potential for more than minimal, isolatedF760Sep 15, 2022

  Based on observations, interviews, and record review, the facility failed to adhere to the parameters ordered by the physician for the administration of blood pressure medication for one (Resident # 31) of five residents observed during medication administration, from a total of 18 residents in the sample. The findings include: During a medication administration observation for Resident #31 on 09/14/22 at 9:37 a.m., Licensed Practical Nurse (LPN) A obtained [MEDICATION(S)] 10 milligrams (mg) and Losartan 100 mg. Both medications had special instructions to hold the medications if the resident's blood pressure (BP) was less than 120/80. LPN A popped the medications into the medication cup, performed hand hygiene and went into Resident #31's room. […]