The Pavilion at Canal Fulton for Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at The Pavilion at Canal Fulton for Nursing and Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF868Jun 18, 2025

  Based on review of facility documentation and interview, the Quality Assurance and Performance Improvement (QAPI) committee failed to meet at least quarterly. This had the potential to affect all 44 residents residing in the facility. Findings include: Review of the facility QAPI committee sign in sheets provided by the facility revealed a single sign-in sheet for May 2025. Interview on 06/17/25 at 4:18 P.M. with the Administrator verified the QAPI committee sign-in sheet dated May 2025 was the only sign in sheet available. No additional information was provided to support additional QAPI meetings were held.

• No harm, potential for more than minimal, widespreadF880Jun 18, 2025

  Based on observation, interview, record review, policy review, and CMS memorandum QSO-24-08-NH review, the facility failed to provide care to Residents #7, #29, and #46 in a manner to prevent the potential spread of infection. This affected Residents #7, #29 and #46 and had the potential to affect all residents residing in the facility. The facility census was 44. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 05/06/14. Diagnoses included multiple sclerosis, atrial fibrillation, and Alzheimer's disease. […]

• No harm, potential for more than minimal, widespreadF804Dec 7, 2022

  Based on observation, interview, and review of meeting minutes, the facility failed to serve palatable food at an appetizing temperature. This affected all 51 residents in the facility. Findings include: During the initial screening, Resident's #5 and #16 on 12/04/22 beginning at 11:12 A.M. reported the food was often cold and of poor quality. Observation of the dinner meal on the South unit on 12/04/22 at 5:00 P.M. revealed multiple residents complained the meal did not look appetizing, the meat was of poor poor quality. The menu indicated the meal was a hot hamburger sandwich with brown gravy, mashed potatoes and carrots. The thin dotted hamburger patty was on top of a piece of bread and covered in brown gravy. Three residents requested the substitution after receiving their meal. […]

• No harm, potential for more than minimal, patternF641Jun 18, 2025

  Based on record review and interview, the facility failed to ensure resident assessments were accurate related to hospice services and use of tobacco. This affected seven residents (Residents #3, #12, #16, #17, #28, #42, and #43) of sixteen residents reviewed for Minimum Date Set (MDS) assessment accuracy. Facility census was 44. Findings include: 1. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and started on hospice services on 03/12/25. Diagnoses included dementia, gastro esophageal reflux disease (GERD), insomnia, anxiety, chronic pain, and Alzheimer's disease. Review of the MDS assessment dated [DATE] revealed the assessment did not indicate the provision of Hospice Services. 2. […]

• No harm, potential for more than minimal, isolatedF558Jun 18, 2025

  Based on observation, interview, record review, and policy review the facility failed to ensure call lights were within resident reach. This affected two (#7 and #23) of two residents reviewed for call lights. The facility census was 44. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 05/06/14. Diagnoses included multiple sclerosis, atrial fibrillation, and Alzheimer's Disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had severe cognitive impairment. required extensive to dependence for all activities of daily living, and was always incontinent of urine and bowel. […]