Pavilion of Ottawa

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 2, 2025

  Based on observation, interview, and record review the facility failed to identify fall risks and follow policy and procedures to prevent falls for two (R1 and R2) of three residents reviewed for falls in the sample of three. These failures resulted in R1 falling from wheelchair to the floor, bleeding, pain, bruising, and hospital visit with a diagnosis of nasal fracture and receiving sutures. These failures also resulted in repeat falls for R2. Findings include: The facility's undated Fall Management policy and procedure documents: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. […]

• Actual harm, isolatedF686Apr 14, 2022

  Based on observation, interview and record review, the facility failed to ensure interventions were in place to prevent skin breakdown and remove compression stockings and assess the underlying skin for skin impairment for one of four residents (R53), reviewed for pressure wounds, in a sample of 41. This failure resulted in the development of multiple, unstageable, necrotic pressure wounds to the feet and heels, a delay in healing with resulting delay in a facility discharge . Findings include: The facility policy, Prevention of Pressure Ulcers/Injuries, dated (revised) 1/2019 directs staff, The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. […]

• No harm, potential for more than minimal, widespreadF812Aug 28, 2025

  Based on observation, interview and record review, the facility failed to ensure food was prepared, stored, and served in a manner to prevent cross-contamination. This failure has the potential to affect all 124 residents in the facility.The findings include:The CMS (Centers for Medicare and Medicaid Services) form 671 dated 8/26/2025 showed 124 residents resided in the facility.On 8/27/2025 at 8:20 AM, V2 (Director of Nursing) said the facility did not have any residents with a feeding tube. On 8/26/2025 between 9:45-10:15 AM, while doing the initial Kitchen observation, a scoop was left inside of the large container of thick-it (a powder used in food preparation to thicken food consistency). The scoop was directly on the powder mixture. […]

• No harm, potential for more than minimal, widespreadF812Sep 29, 2023

  Based on observation, interview, and record review, the facility failed to ensure the staff covered hair in a sanitary manner while in the kitchen. This failure has the potential to affect all 124 residents at the facility. Findings include: The facility's Hair Restraints/Jewelry/Nail Polish/False Eyelashes Policy, Dated 2017, documents: Food and nutrition services employees shall wear hair restraints and beard guards. Hairnets will be worn at all times in the kitchen. On 9/26/23 at 10:25am, V6 Dietary Manager was observed with staff in the facility kitchen. V6's hair on the back of her head was uncovered. V10 Cook and V11 Cook were preparing the facility's lunch meal for residents. V10 and V11 were observed to have hair uncovered on the sides and/or back of their heads. […]

• No harm, potential for more than minimal, widespreadF880Jul 27, 2023

  Based on observation, interview, and record review the facility failed to identify a potential viral infection, immediately report signs and symptoms to the Medical Director, remove potential symptomatic staff from work, obtain stool/emesis specimens, and delayed diagnosis. These failures resulted in continuation of the spread of an unknown virus to 53 (R1 through R53) of 129 residents and 24 staff experiencing varying symptoms of nausea, vomiting, diarrhea, chills and elevated temperature. […]