Pavilion on Pico Healthcare & Wellness Centre, LP

In the surveyor’s words

From the most serious findings on record at Pavilion on Pico Healthcare & Wellness Centre, LP, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jul 29, 2021

  Based on observation, interview, and record review the facility failed to ensure six of 17 sampled residents (Residents 1, 5, 14, 15, 16, and 17) were free of neglect when the facility failed to ensure: a) Licensed Nursing Staff (LNS) assessed Residents 1, 5, 15 and 17's pressure ulcers (PU, injury to skin and underlying tissue due to prolonged pressure over a bony structure) on a weekly basis, according to the facility's policy and procedures and professional standards of practice, b). LNS fully implemented Residents 1, 5, 15, and 17's care plans for skin and pressure wound treatments. c). LNS entered Medical Doctor (MD) 7's orders for PU and turning and repositioning into the medical records of Residents 1, 5, 15 and 17, or LNS documented when or if MD 7's orders were performed, d). […]

• Immediate jeopardy, patternF686Jul 29, 2021

  Based on observations, interviews, and record reviews, the facility failed to provide services needed to prevent or treat pressures ulcers (PU, an area of the skin that died because the patient laid or sat on that area of skin so long that blood stopped flowing to that area of skin) and vascular ulcers ([NAME], when an area of skin dies because blood vessels do not allow blood to circulate to that area of skin) for four of four sampled residents (Residents 1, 5, 15, and 17) when: a). The facility did not ensure that licensed nursing staff (LNS) assessed Residents 1 and 5's level of risk for developing pressures ulcers, according to the facility's policy, b). […]

• Immediate jeopardy, isolatedF760Apr 4, 2023

  Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) was not administered Glipizide (a medication for diabetes mellitus [DM-high blood glucose/sugar levels]) on 2/9/2023. Resident 1 did not have DM and did not have an order to receive Glipizide. This deficient practice resulted in Resident 1 having altered mental status (AMS - a change in mental status that can be life threatening), diaphoresis (excessive sweating), and seizure activity (sudden uncontrolled body movements) on 2/9/2023. Resident 1's blood glucose level was 24 (below 40 is considered severe hypoglycemia [severely low blood sugar], a life-threatening and needs immediate medical treatment, if not treated can result in a coma and/or death. […]

• Actual harm, isolatedF697Jul 29, 2021

  Based on interview and record review, the facility failed to ensure one of 17 sampled residents (Resident 16) was provided pain management during the first 12 hours from admission after a recent surgery (date and name of surgery not indicated), to repair a broken ankle. On 5/17/2021, after Resident 16 was admitted at 9 p.m., having pain on his left ankle, he did not receive pain management and pain medication until 12 hours later This deficient practice resulted in Resident 16 having uncontrolled pain to the left ankle from 5/17/2021 to 5/18/2021. Findings: A review of Resident 16's Face Sheet indicated the facility admitted the resident on 5/17/2021 from a General Acute Care Hospital (GACH) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF760Jul 29, 2021

  Based on interview and record review the facility failed to ensure two of 17 sampled residents (Residents 14 and 16) were free of significant medication errors by: 1. Not administering Resident 14 the medication [MEDICATION(S)] (medication that contains a combination of [MEDICATION(S)] and [MEDICATION(S)] which are central nervous system stimulants that affect chemicals in the brain and nerves that contribute to [CONDITION(S)] and impulse control. [MEDICATION(S)] helps to improve concentration and focus) 10 milligrams (mg- unit of measurement) tablet, 11 days (From 5/8/2021 through 5/19/2021) after the physician ordered the medication. 2. […]