The Pavilion at Creekwood

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Jan 5, 2025

  Based on interviews and record reviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #2) of 3 residents reviewed for quality of care. RN C failed to assess and notify the physician when Resident #2 fell in the bathroom on 10/05/24. The resident required hospitalization and suffered a clavicle fracture. On 01/03/25 at 1:40 PM, an Immediate Jeopardy (IJ) was identified. […]

• Immediate jeopardy, isolatedF689Jan 5, 2025

  Based on interview and record review, the facility failed to provide adequate supervision and assistance to prevent accidents and injury for 1 of 3 residents (Resident #3) reviewed for accidents and supervision. CNA A and RN B failed to ensure that Resident #3 was not left alone in the shower chair in his room. As a result, Resident #3 fell out of the shower chair, obtaining a hematoma to his head and being sent to the hospital. On 01/03/25 at 5:00 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 01/05/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. […]

• Immediate jeopardy, isolatedF742Jan 5, 2025

  Based on observations, record reviews, and interviews the facility failed to ensure that a resident who was diagnosed with a mental illness or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for one (Resident #1) of 5 residents reviewed for services for mental/psychosocial concerns, in that: LVN O failed to follow the facility's suicide policy when Resident #1 made an outcry of self-harm on 01/01/25. An IJ was identified on 01/03/25. The IJ template was provided to the facility on [DATE] at 5:09 PM. […]

• Immediate jeopardy, isolatedF578Aug 27, 2024

  Based on observation, interview, and record review, the facility failed to protect the residents right to request, refuse, and/or discontinue treatment for one (Resident #1) out of six residents reviewed for advanced directives, in that: The facility failed to honor the rights of Resident #1's wishes to die a dignified death by failing to honor a signed OOH DNR order on [DATE] at 07:42 pm when LVN A failed to inform EMS of Resident #1's DNR status and a full code was initiated to include CPR for approximately 43 minutes when Resident #1 became unresponsive. An Immediate Jeopardy (IJ) was identified on [DATE] at 03:25 PM. The IJ template was provided to the facility on [DATE] at 03:41 PM and signed by the Administrator. […]

• No harm, potential for more than minimal, widespreadF812Jan 25, 2024

  Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the refrigerator and freezer located in the kitchen. This failure could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 01/23/24 at 8:30 AM revealed: - 1 box of homestyle ring donuts open and exposed to air; and - 1 box of turkey bacon open and exposed to air. […]