Pavilion-Ths, Llc

In the surveyor’s words

From the most serious findings on record at Pavilion-Ths, Llc, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF656Mar 27, 2025

  Based on policy review, medical record review, observation, and interview, the facility failed to implement a person-centered care plan to address the code status for 21 of 24 (Resident #2, #4, #5, #9, #11, #15, #16, #17, #19, #22, #25, #27, #29, #32, #33, #34, #45, #48, #51, #207 and #257) sampled residents and failed to implement a fall intervention for 1 (Resident #18) of 6 residents reviewed for accidents. The findings include: 1. Review of the undated facility policy titled, Comprehensive Care Plans, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing .needs .The comprehensive care plan will describe, at a minimum .The services that are to be furnished to attain or… […]

• No harm, potential for more than minimal, isolatedF686Jun 17, 2026

  Based on policy review, medical record review, observation, and interview, the facility failed to follow the Physician's Order for wound treatment on 1 of 2 (Resident #2) residents reviewed for pressure ulcers. The findings include: 1. Review of the facility's policy titled Wound Treatment Management, dated 2025, revealed .Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.The facility will follow specific physician orders for providing wound care. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Pressure Ulcer Sacral Region, and Cerebrovascular Disease. […]

• No harm, potential for more than minimal, isolatedF695Jun 17, 2026

  Based on facility policy review, medical record review, observation, and interview, the facility failed to follow Physician's Orders for oxygen therapy for 1 of 1 (Resident #20) residents reviewed for respiratory care. The findings include: Review of the undated facility policy titled, Oxygen Administration, revealed .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.Oxygen is administered under orders of a physician. […]

• No harm, potential for more than minimal, isolatedF880Jun 17, 2026

  Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure infection control practices to prevent the spread of communicable diseases for 1 of 2 (Resident #6) residents sampled reviewed for the use of Enhanced Barrier Precautions (EBP). The findings include: Review of the undated facility policy titled, Enhanced Barrier Precautions, revealed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Initiation of Enhanced Barrier Precautions.An order for enhanced barrier precautions will be obtained for residents with any of the following.indwelling medical devices.hemodialysis catheters.even if the resident is not known to be infected or… […]

• No harm, potential for more than minimal, isolatedF578Mar 27, 2025

  Based on facility policy review, medical record review and interview, the facility failed to accurately address an advanced directive for 1 (Resident #16) of 24 residents reviewed. The findings include: 1. Review of the undated facility policy titled, Residents' Rights Regarding Treatment and Advance Directives, revealed .It is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate advance directives .Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State Law .relating to the provision of health care when the individual is incapacitated .On admission, the facility will determine if the resident has executed… […]