The Pavilion at Kenton

In the surveyor’s words

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

• Actual harm, isolatedF656Aug 14, 2026

  Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure staff followed its policy and the resident-centered, comprehensive care plan for 1 of 32 residents, Resident (R) 79.R79 had been dependent on staff for total care and mobility since her admission in 2021. However, staff failed to follow and implement R79's care plan intervention for the use of a mechanical lift for all transfers. Review of the facility's Investigation Statement, dated 07/13/2026, revealed Certified Nursing Assistant (CNA) 9 admitted to transferring R79 to bed using a scoop method and not the care planned mechanical lift. […]

• Actual harm, isolatedF689Aug 14, 2026

  Based on interview, record review, and review of facility documentation and policy, the facility failed to ensure an environment free of accidents hazards by failing to use/provide the necessary assistance/device required during transfer of 1 of 32 sampled residents. (Resident (R) 79). On 07/13/2026, R79 was observed with a large bruise and swelling to her right upper extremity. Review of the facility's investigation documentation revealed CNA 9 failed to follow R79's care-planned intervention requiring the use of a mechanical lift with a two-person assist for transfers and instead manually transferred R79 to the bed. The investigation further revealed CNA 9 continued dressing R79 and reported hearing a pop. […]

• No harm, potential for more than minimal, widespreadF867Aug 14, 2026

  Based on interview, record review, and review of facility documentation and policy, the facility failed to have an effective process in place to address systemic failures through its Quality Assurance Performance Improvement (QAPI) process. As a result of the failure the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained as required. The systemic failure placed residents at increased risk for lack of quality of care and preventable infectious diseases.The State Survey Agency (SSA) identified continued non-compliance cited on the previous standard survey on 03/26/2026 under 42 CFR 483.25 Quality of Care (F693) Enteral Feeding, and 42 CFR 483.80 (F880) Infection Control. […]

• No harm, potential for more than minimal, widespreadF725Mar 26, 2026

  Based on interview, record review, review of the Facility Assessment, and review of the facility's documents and policy, the facility failed to maintain sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population. Review of the facility's staffing for the past 30 days revealed the facility consistently failed to provide sufficient staff as determined in the Facility Assessment to ensure resident needs were met. […]

• No harm, potential for more than minimal, widespreadF804Mar 26, 2026

  Based on observation, interview, and review of the facility's documents and policy, the facility failed to provide food and drink served at a safe and appetizing temperature to residents. The lunch test tray on 03/24/2026 revealed food items that were in the temperature danger zone range for both hot and cold foods. Resident attendees in the Resident Council meeting on 03/23/2026 stated they received cold food at mealtimes. Also, on 03/23/2026, Resident (R) 45 stated she received cold food all the time. This deficient practice had the potential to affect all 78 current residents that received food prepared in the kitchen. […]