Pavilion at Brandon Wilde

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure grievances were promptly resolved for five residents (Resident (R) 9) R23, R35, R50, and R61 of 22 sample residents. Specifically, the facility failed to date, summarize findings, and document corrective action taken as a result of the grievance. This failure had the potential to cause further grievances to be unresolved for residents throughout the facility. 1. Review of R23's ) revealed a quarterly Minimum Data Set (MDS)'' assessment, located under the ''MDS'' tab electronic medical record (EMR), with an Assessment Reference Date (ARD) of 03/13/26 revealed R23's admission date was 08/26/25. R23 had a diagnosis that included kidney insufficiency. R23 had a Brief Interview for Mental Status (BIMS)score of 14 out of 15 which indicated no cognitive impairment. 2. [...]

Inspectors wroteBased on record review, interviews, and facility policy, the facility failed to ensure a Georgia Criminal History Check System (GCHEXS) fingerprint background check was completed prior to date of hire for one of seven new hire employees and reference checks were completed for seven of seven new hire employees. The deficient practice could result in a staff with an unknown criminal background having access to residents. 1. Review of employee records for the Administrator revealed he was hired on 12/01/25. The required GCHEXS fingerprint background check was completed on 12/02/25. During an interview on 04/17/26 at 3:42 PM, the Human Resources Director (HRD) stated GCHEXS background checks are completed for all employees except nurses and are required to be completed prior to the start date. [...]

Inspectors wroteBased on record review, interview, and facility policy, the facility failed to ensure residents were informed of the benefits, risks, and alternatives of treatment prior to initiating psychotropic medication for one (Resident (R) 42) of five residents reviewed for unnecessary medications out of a total sample of 22 residents. This failure increased the risk of residents not knowing the potential side effects of the medications. 1. Review of R42's admission Record located under the Profile tab of the electronic medical record (EMR), revealed R42 was admitted to the facility on [DATE] with diagnoses that included depression, dementia, and anxiety disorder. [...]

Inspectors wroteBased on record review, interview, and review of facility's policy, the facility failed to convey information to hospital at the time of transfer, failed to notify resident and resident representative in writing of the reason for the transfer/discharge to the hospital, and failed to notify the resident/resident representative of the facility policy for bed hold including reserve bed payment. one of three residents (Resident (R) 7) reviewed for hospitalization out of 22 sampled residents. This failure creates the potential for residents and responsible parties to be misinformed of the transfer out of the facility and to not have the information needed to safeguard their return to the facility. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure the Discharge Return Anticipated Minimum Data Set (MDS) was completed for one of three residents (Resident (R) 7) reviewed for hospitalization out of a total sample of 22 residents. This had the potential to lead to inaccurate goals of care, including functional and health status and strengths and needs of the resident.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure the comprehensive assessment accurately reflected a discontinued antipsychotic medication for one (Resident (R) 22) of five residents reviewed for unnecessary medications in the sample of 22 residents. This failure had the potential to lead to a lack of alternative interventions. Review of R22's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R22 was admitted on [DATE] with diagnoses of Alzheimer's disease and dementia with behavioral disturbance. Review of R22's monthly Pharmacy Review provided by the facility revealed a pharmacy recommendation to discontinue quetiapine 25 milligrams (mg) one tablet by mouth daily starting on 03/05/26. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a physician's order for oxygen was obtained prior to administering oxygen; ensure appropriate oxygen signage was posted on the resident's door; and ensure respiratory supplies were dated and stored in a sanitary manner in accordance with professional standards for one of one residents (Resident (R) 68) reviewed for respiratory care out of a sample of 22 residents. This failure had the potential to compromise infection control and increase the risk of infection transmission within the facility. Cross Reference F658Findings include:Review of R68's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R68 was admitted on [DATE] with a diagnosis of pneumonitis due to inhalation of food and vomit. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure personal resident refrigerators were maintained to prevent potential food borne illness for two residents of two sampled residents (Resident (R)33) and R50) who owned a refrigerator. This failure had the potential to cause the residents to eat spoiled food which could cause a decline in the residents' overall health.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Dignity, the facility failed to treat residents with dignity for one out of three Residents (R) (R8) observed during dining and for one out of three Residents (R) (262) observed during medication administration. Specifically, the facility failed to ensure R8 received a meal tray at mealtime due to a lack of sufficient dining table space causing R8 to observe other residents eating their meals while waiting for a space to become available and assistance. In addition, the facility failed to ensure R262's blood glucose testing procedure was completed in a private area to protect the resident's dignity.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility's policy titled Administering Oral Medications, the facility failed to ensure care and services were provided in accordance with accepted professional standards for one out of three Residents (R) (R55) observed during medication administration. Specifically, Registered Nurse (RN) (RN#7) withheld R55's physician-ordered medications without consulting with the physician for an order to do so.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled, Medication Holds and Administering Oral Medications, the facility failed to ensure the medication error rate was less than 5% for two out of Residents (R) (R55 and R29) of three residents observed during medication administration. Observation of medication administration revealed 4 medication errors out of 31 opportunities, which resulted in a medication error rate of 12.9 %.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Administering Oral Medications, the facility failed to ensure medications were accurately labeled for one out of three Residents (R) (R55) observed during medication administration.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Infection Prevention and Control Program, the facility failed to ensure infection control practices to prevent the potential spread of infection were maintained during medication administration for residents receiving medications from one of four medication carts observed. The failed practice affected one out of three Residents (R) (R55) observed during medication pass and one out of one (R262) observed receiving a blood glucose check. [...]

Inspectors wroteBased on staff interviews, record reviews, and review of the facility's policy titled, Accepting Delivery of Medications, the facility failed to administer medications per physician's orders for one resident (R) (R4). Specifically, the facility failed to ensure that R4 received baclofen (muscle relaxant) and vitamin B12 (water-soluble vitamin) as ordered by the physician.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Self-Administration of Drugs, the facility failed to assess six of 28 residents (R) R#33, R#53, R#55, R#54, R#20, and R#2 reviewed for the ability to self-administer medications prior to leaving medications at the bedside. The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Urinary Drainage Bag; the facility failed to maintain dignity by ensuring a dignity bag was provided for three residents (R) (R33, R55, and R2) of 28 residents reviewed for an indwelling urinary catheter.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Care Planning - Comprehensive Preliminary, the facility failed to implement a care plan intervention for one of four residents (R) (R2) reviewed with an urinary catheter. Specifically, the facility failed to ensure the resident's urinary catheter drainage bag was placed in a privacy bag as instructed on the care plan. The sample size was 28 residents.

Inspectors wroteBased on observations, staff and resident interviews, record review, and a review of the facility's policies titled, Administering Medications through a Small Volume (Handheld) Nebulizer, and Oxygen Therapy - Mask And Nasal Cannula the facility failed to ensure oxygen equipment was properly stored while not in use and failed to properly administer and assess resident after nebulizer treatment for four (4) residents (R) (R33, R52,R20, and R26) receiving treatment for respiratory care. The deficient practice had the potential to increase the risk of respiratory complications and infection. The sample size was 28.

Inspectors wroteBased on resident and staff interviews, record review and review of the facility policy titled Hemodialysis Access Care, the facility failed to ensure communication between the facility and the dialysis center was documented after each dialysis treatment for one of one resident (R) (R 20) reviewed for dialysis care. The sample size was 28 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that PRN [as needed] orders for antipsychotic drugs were limited to 14 days and failed to document the rationale for the extended duration for the PRN order for one of five residents (R) R45 reviewed for medication management. This failure had the potential to affect the resident's highest practicable mental, physical, and psychosocial well-being. The sample size was 28 residents.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy titled, Lab and Diagnostic Test Result- Clinical Protocol the facility failed to follow a Nurse Practitioner's (NP) order to collect a urine specimen to send to the laboratory for a urinalysis in a timely manner for one resident (R) (R11) of 24 sampled residents. This failure placed the resident at risk for medical complications and delay of treatment.