The Pavilion at Piketon

In the surveyor’s words

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

• Actual harm, isolatedF688Jan 29, 2024

  Based on medical record review, observation, staff interview, and facility policy review, the facility failed to develop and implement comprehensive and individualized interventions to prevent the onset of joint contractures for Resident #38. Actual harm occurred on 01/10/24 when Resident #38, who was admitted to the facility without contractures was assessed to have developed contractures to the third and fourth fingers on the left and right hands which caused pain upon range of motion for the resident due to a lack of interventions to prevent the contractures from occurring. This affected one (Resident #38) of one resident reviewed for range of motion. […]

• Actual harm, isolatedF689Jan 29, 2024

  Based on medical record review, observation, staff interview, review of hospital progress notes, review of the facility policy, and review of manufacturer's guidelines, the facility failed to ensure Resident #70 was provided adequate and necessary interventions to prevent falls including a fall with injury and failed to ensure post-fall investigations were completed for Resident #69. This affected two residents (Resident #69 and #70) of four residents reviewed for falls. The facility census was 84. […]

• No harm, potential for more than minimal, widespreadF921Apr 18, 2023

  Based on observations, staff interviews, plumbing company interview and, review of plumbing invoices and quotes, this facility failed to timely fix/replace a non-working hot water heater that was used to provided hot water to the facility's laundry room. This had the potential to affect all residents residing in the facility at this time. The facility census was 81. Findings included: Review of the provided Quote from a local Plumbing, Heating and Cooling Company #1 dated 02/28/23 revealed the facility was provided a quote for the cost of $18,125.25 to replace the water heater in the facility ' s laundry room and for the labor to complete this work. Summary of work included: 1. Backordered - Expected May 26, 2023, through August 24, 2023. 2. Remove the existing water heater. 3. […]

• No harm, potential for more than minimal, widespreadF868May 19, 2022

  Based on record review and staff interview the facility failed to ensure quarterly Quality Assessment and Assurance (QAA) meetings were conducted. This had the potential to affect all 84 residents residing in the facility. Findings Include: Review of the QAA sign in sheets from 2021 and 2022 revealed meetings were held on 07/29/21 and 11/19/21. The facility failed to provide any additional sign in sheets to reflect quarterly meetings being conducted. Interview with the Administrator on 05/19/22 at 1:50 P.M. verified no further meeting sign in sheets could be found or provided as the only records were from meetings held on 07/29/21 and 11/19/21.

• No harm, potential for more than minimal, patternF758Jan 29, 2024

  Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure target behaviors were identified and monitored in conjunction with the use of anti-psychotic medications. This affected four (Residents #15, #54, #59, and #76) of 22 facility-identified residents with orders for anti-psychotic medications. The facility census was 84. Findings include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses including bipolar disorder, dementia with other behavioral disturbances, and hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #15 dated 12/20/23, revealed the resident was mildly cognitively impaired and received anti-psychotic medication on a routine basis. […]