Pavilion Health Center at Brightmore

In the surveyor’s words

From the most serious findings on record at Pavilion Health Center at Brightmore, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 9, 2025

  Based on record review, video footage, observations, and interviews with family members, staff, the Medical Director, Police Officer, and Fire Captain, the facility failed to supervise a severely cognitively impaired resident (Resident #1) from exiting the facility without staff knowledge on 11/22/25 (Saturday) at approximately 10:28 AM on foot for 1 of 3 residents reviewed for supervision to prevent accidents. Resident #1 who had a primary diagnosis of toxic encephalopathy (neurological disorder caused by exposure to toxic substances, leading to diffuse brain dysfunction) exited from the facility without staff's knowledge for over two hours on the morning of 11/22/25. […]

• Immediate jeopardy, isolatedF600Mar 26, 2024

  Based on record review, resident interviews, family interviews and staff interviews the facility failed to protect Resident #28 from neglect when he was not administered scheduled nebulizer treatments (medical device that delivers liquid directly into the lungs) as ordered by Hospice despite repeated requests. Resident #28 had a diagnosis of chronic obstructive pulmonary disease with oxygen use and had orders for nebulizer treatments at 9:00 am, 11:00 am, 1:00 pm and 5: 00 pm during the 7:00 am to 7:00 pm (day shift). Resident #28 reported he was only administered one nebulizer treatment during the day shift on 3/9/24 and 3/10/24 and experienced chest pain on 3/9/24. […]

• Immediate jeopardy, isolatedF760Mar 26, 2024

  Based on record review and resident, family member, staff interviews, Hospice Nurse, Nurse Practitioner (NP), and Medical Director interviews the facility failed to prevent a significant medication error when Resident #28 was not administered scheduled nebulizer treatments (medical device that delivers liquid directly into the lungs) as ordered by Hospice despite repeated requests. Resident #28 had a diagnosis chronic obstructive pulmonary disease with oxygen use and had orders for nebulizer treatments at 9:00 am, 11:00 am, 1:00 pm and 5: 00 pm during the 7:00 am to 7:00 pm (day shift). Resident #28 reported he was only administered one nebulizer treatment during the day shift on 3/9/24 and 3/10/24 and experienced chest pain on 3/9/24. […]

• Actual harm, isolatedF550Sep 29, 2022

  Based on observation, resident and staff interviews and record review, the facility failed to provide care in a manner to maintain the resident's dignity by not providing incontinence care when requested. This resulted in Resident #37 crying while waiting for incontinence care and she reported it made her feel worthless, horrible, bad and didn't deserve to be treated that way. This was evident for 1 of 6 residents who were reviewed for dignity and respect (Resident #37). Findings included: Resident #37 was admitted to the facility on [DATE]. A review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #37 was cognitively intact. […]

• Actual harm, isolatedF677Sep 29, 2022

  Based on observations, resident and staff interviews, and record review, the facility failed to provide incontinence care when requested for 1 of 6 residents (Resident #37) reviewed for activities of daily living (ADL). Findings included: Resident #37 was admitted to the facility on [DATE]. A review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #37 was cognitively intact. Resident #37 needed extensive assisted with all activities of daily living with the exception of eating. No issues of refusals of care noted. A review of an ADL care plan dated 09/02/22 revealed Resident #37 required assistance with ADL care and was incontinent of bowel and bladder. Interventions included instructions to check on her frequently and provide incontinence care as needed. […]