The Pavilion at Edgefield for Nursing and Rehabili

In the surveyor’s words

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

• Actual harm, isolatedF686Jan 19, 2024

  Based on record review, observation, resident and staff interview, review of the facility policy, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement a comprehensive and individualized pressure ulcer prevention program for Resident #25 to prevent the development of an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer. The facility also failed to accurately assess the wound as a facility acquired pressure ulcer. […]

• No harm, potential for more than minimal, widespreadF809May 11, 2026

  Based on observation, interview, and facility policy review, the facility failed to ensure snack items were available at all times for residents. This had the potential to affect all 61 residents who received meals/snacks from the kitchen. Findings Include:Observations on 05/11/26 from 9:00 A.M. to 9:41 A.M. during the initial facility tour revealed no snack trays/storage visible anywhere on all three residential hallways.Observation on Monday, 05/11/26, during the kitchen tour at 10:10 A.M. revealed in the dry food stock room the shelf was empty of snack items for the residents.Interview on 05/11/26 at 10:15 A.M. with the Dietary Manager #260 confirmed the shelf in the dry food stock room was empty of snack items. […]

• No harm, potential for more than minimal, widespreadF880Feb 18, 2026

  Based on observation, interview and review of facility policy, the facility did not ensure infection control practices were maintained in three of three linen closets for sanitary linen storage. This had the potential to affect all 64 residents residing in the facility. Findings include:An observation was conducted on 02/17/26 at 10:50 A.M. with Certified Nursing Assistant (CNA) #329 of the second floor clean storage linen closet. A very large pile of socks was on the ground in the closet with a dirty pair of shoes on top of the socks. Multiple items of clothing, hospital gowns and bedsheets were on the ground, and various items of trash were sitting on shelving units with clean linens. An interview with CNA #329 at the time of the observation confirmed the findings. […]

• No harm, potential for more than minimal, widespreadF812Nov 20, 2025

  Based on observations, staff interviews, review of kitchen staff education, review the owner's manual for the facility dishwasher, and policy review the facility failed to ensure the kitchen was maintained in a sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 63. Findings include: Observation on 09/15/25 at 9:55 A.M. of the dishwasher machine revealed the dishwasher was a low temperature dishwasher. When asked if they check the sanitizer of the dishwasher, the surveyor was told no by Dietary Aide #990. Dietary Aide #990 stated she has never checked the sanitizer for the dishwasher since she started. Dietary Aide #990 stated she had worked at the facility for a few months. Interview on 09/15/25 at 10:00 A.M. […]

• No harm, potential for more than minimal, patternF578Nov 20, 2025

  Based on record review, policy review, and interview the facility failed to ensure accuracy of code status and educate staff on the location of the resident current code status. This affected six (#01, #10, #12, #15, #27 and #32) of 24 residents reviewed. The census was 63.Findings include: 1. Review of Resident #15's medical record revealed a 05/01/25 admission date with diagnoses including dementia, fracture of left femur, emphysema, severe protein calorie malnutrition, disorders of psychological development, Alzheimer's disease, ataxia, muscle weakness, varus deformity left hip, bradycardia, joint implants, vitamin D deficiency, abnormal findings of lung fields, major depressive disorder, osteoarthritis, cataract, elevated white blood cell count, anxiety, cataracts, constipation,… […]