The Pavilion at Crescent Lake

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Oct 7, 2021

  Based on observation, interview, and record review, the facility failed to serve food in accordance with professional standards for food service safety. Findings: An observation of the nourishment room on the second floor on 10/4/2021 at 1:45 PM with the Dietary Manager showed the ice machine had a black substance on the bottom edge of the baffle (ice guard) (Photographic evidence obtained). During an interview on 10/4/2021 at 1:46 PM, the Dietary Manager stated, The ice machine is to be cleaned twice a month. […]

• No harm, potential for more than minimal, patternF756Jan 8, 2026

  Based on record review and interview, the facility failed to ensure the physician(s) wrote a reason for disagreement with the Resident Pharmacist Recommendations for 5 of 5 residents, Residents #2, #6, #8, #10, and #26. Findings include: Review of Resident #6's Pharmacist Recommendation dated 9/22/25 read, recommended spacing dosing of hydrocodone and valium. The physician checked disagreed and continued both medications, no reason for the decision was documented. Review of Resident #6's Pharmacist Recommendations dated 6/30/25 and 8/9/25 read, This resident is currently taking Diazepam 10 mg [milligrams] HS [hour of sleep] for anxiety. Literature indicates the maximum recommended dose for geriatric residents is 5mg/daily. […]

• No harm, potential for more than minimal, patternF812Aug 1, 2024

  Based on observation, interview, and policy and procedure review, the facility failed to ensure food is safely stored, covered, and/or labeled in the areas of the nutrition room and food trays delivered to the floors. Findings include: During an observation on 7/29/24 at 10:00 AM of the nutrition room on the first floor, inside the refrigerator was an open package of Bologna not dated or sealed. (Photographic evidence obtained). During an interview on 7/29/24 at 10:00 AM the Dietary Manager stated, Its dietary's responsibility to check the nourishment rooms in the morning and clean them out as needed. […]

• No harm, potential for more than minimal, patternF569Oct 7, 2021

  Based on record review and interview, the facility failed to ensure residents that received Medicaid benefits were notified when the amount in the resident's account reached $200 less than the SSI (Supplemental Security Income) resource limit for 2 of 3 residents, Residents #24 and #3, in a total sample of 28 residents. Findings: Review of Resident #24's trust account activity beginning on 3/8/2021 revealed a balance of $2,765.89. There was no documentation showing the resident was notified his account was over the eligible limit. The account balance on 4/5/2021 revealed a balance of $1,981.99. There was no documentation showing the resident was notified his account was over the eligible limit. The account balance on 6/9/2021 was $1,805.14. […]

• No harm, potential for more than minimal, isolatedF584Jan 8, 2026

  Based on observation, interview, and record review the facility failed to ensure residents had a clean, homelike environment. Findings include: During an observation on 1/5/2026 at 10:12 AM Resident #76's bathroom on the left-hand side toward the bottom corner of the door was rusted and metal portions of the door frame were exposed and extended outward. (Photographic evidence obtained) During an observation on 1/5/2026 at 10:15 AM Resident #58's room wall where the sink is located has peeling paint and drywall exposed with holes. […]