Pavilion on Main Street, The

In the surveyor’s words

From the most serious findings on record at Pavilion on Main Street, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jan 17, 2023

  Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by staff for one of three residents (R2) reviewed for abuse in the sample of 8. This failure resulted in bruising and R2 crying and distressed into the following day. The Immediate Jeopardy began on 12/3/22 when V20 (Certified Nursing Assistant/CNA) heard R2 screaming after V22 (CNA) entered R2's room to provide care. V2 (Director of Nursing/DON) and V4 (Regional Director of Operations/RDO) were notified of the Immediate Jeopardy on 1/13/23 at 11:00 AM. V1 (Administrator) was on leave. […]

• Actual harm, isolatedF689Sep 18, 2025

  Based on observation, interview, and record review, the facility failed to ensure a bed rail was maintained in a safe manner for 1 of 3 residents (R1) reviewed for resident injury in the sample of 9. This failure resulted in R1 receiving an injury to her right lateral leg, being sent to a local hospital where she received stitches for her injury.The findings include:R1's admission Record, printed by the facility on 9/16/2025, showed she had diagnoses including, but not limited to, displaced comminuted fracture of shaft of humerus left arm (5/6/25), moderate protein-calorie malnutrition, difficulty in walking, reduced mobility, lack of coordination, pain in left should and left elbow, disorders of muscle, dysphagia, unsteadiness on feet, need for assist with personal care, age-related… […]

• Actual harm, isolatedF689Aug 27, 2025

  Based on observation, interview and record review the facility failed to safely handle a resident to prevent multiple skin tears. This failure resulted in R92 being transferred to the emergency room (ER) after a transfer which contributed to R92 sustaining a large skin tear requiring 11 stitches/sutures. This applies to 1 of 23 residents (R92) reviewed for safety in the sample of 23. Findings include:R92's progress notes dated 8/23/25 shows, Resident noted with a skin injury to the left lower leg. The incident occurred during transfer from the wheelchair to the bed, the CNA (certified nursing assistant) reported. MD (V21 R92's medical doctor (MD)) is informed with order to transfer resident to ER. […]

• Actual harm, isolatedF692Aug 27, 2025

  Based on observation, interview and record review the facility failed to ensure dietary recommendations were implemented for residents with a history of significant weight loss. This failure resulted in R43 and R93 not receiving their therapeutic diets as ordered for their severe weight loss. This applies to 2 of 9 residents (R43, R93) reviewed for weight loss in the sample of 23. Findings include:On 8/25/25 at 10:32 AM, V5 Dietary Manager added 21 cooked, individual chicken nuggets into the facility's food processor. V5 stated, she was making puree for 11 residents. V5 stated, regular diets will get 5 chicken nuggets per person. (There should have been 55 nuggets pureed for 11 pureed diets but only pureed half of the amount she should have). […]

• Actual harm, isolatedF697Sep 28, 2023

  Based on observation, interview, and record review the facility failed to provide pain control for a resident with fractured ribs for 1 of 1 resident (R289) reviewed for pain. This failure resulted in R289 experiencing difficulty sleeping, difficulty participating in therapy and uncontrolled pain. The findings include: R289's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include multiple fractures of ribs, left side, need for assistance with personal care, abnormalities of gait and mobility, opioid dependence, spinal stenosis, low back pain, and intervertebral disc degeneration lumbar and lumbosacral region. […]