Pavilion Health Center at Brightmore

Inspectors wroteBased on record review, video footage, observations, and interviews with family members, staff, the Medical Director, Police Officer, and Fire Captain, the facility failed to supervise a severely cognitively impaired resident (Resident #1) from exiting the facility without staff knowledge on 11/22/25 (Saturday) at approximately 10:28 AM on foot for 1 of 3 residents reviewed for supervision to prevent accidents. Resident #1 who had a primary diagnosis of toxic encephalopathy (neurological disorder caused by exposure to toxic substances, leading to diffuse brain dysfunction) exited from the facility without staff's knowledge for over two hours on the morning of 11/22/25. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a resident had an indication and a diagnosis for the use of an antipsychotic medication. This was for 1 of 5 residents for chemical restraints (Resident #49).

Inspectors wrote2. Resident #92 was admitted to the facility on [DATE]. A review of a social service progress note dated 05/07/2025 at 10:11 AM stated Resident #92 had a planned discharge to an assisted living facility. A review of the discharge MDS assessment dated [DATE] revealed that the discharge status had been coded as discharge to hospital. An interview on 06/25/2025 at 11:15 AM with the MDS Coordinator indicated she received a resident's discharge information through progress notes, discussions with the Social Worker or weekly utilization review meetings. The interview revealed she was newer to the role of MDS Coordinator and had just coded Resident #92 went to the hospital by mistake. She stated it should have reflected the resident was discharged to an assisted living facility. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to develop personalized comprehensive care plans in the areas of oxygen therapy (Resident #16) and include accurate interventions in a care plan (Resident #41) for 2 of 21 residents reviewed for comprehensive care plans.

Inspectors wroteBased on record review and staff interviews the facility failed to develop a comprehensive care plan within 7 days of completing a comprehensive assessment for 1 of 21 residents (Resident #56) reviewed for care plans.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to use sterile gloves and failed to perform hand hygiene while providing tracheostomy care to Resident #62. This deficient practice occurred for 1 of 1 resident observed for tracheostomy care (Resident #62).

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 5 medication errors out of 27 opportunities, resulting in a medication error rate of 18.52% for 1 of 4 residents (Resident #49) observed during the medication administration observation.

Inspectors wroteBased on record review, resident interviews, family interviews and staff interviews the facility failed to protect Resident #28 from neglect when he was not administered scheduled nebulizer treatments (medical device that delivers liquid directly into the lungs) as ordered by Hospice despite repeated requests. Resident #28 had a diagnosis of chronic obstructive pulmonary disease with oxygen use and had orders for nebulizer treatments at 9:00 am, 11:00 am, 1:00 pm and 5: 00 pm during the 7:00 am to 7:00 pm (day shift). Resident #28 reported he was only administered one nebulizer treatment during the day shift on 3/9/24 and 3/10/24 and experienced chest pain on 3/9/24. In addition, Resident #28 stated during the day shift on 3/9/24 when he requested a dietary supplement he was told there were not any. No vital signs were documented on the day shift on 3/9/24. [...]

Inspectors wroteBased on record review and resident, family member, staff interviews, Hospice Nurse, Nurse Practitioner (NP), and Medical Director interviews the facility failed to prevent a significant medication error when Resident #28 was not administered scheduled nebulizer treatments (medical device that delivers liquid directly into the lungs) as ordered by Hospice despite repeated requests. Resident #28 had a diagnosis chronic obstructive pulmonary disease with oxygen use and had orders for nebulizer treatments at 9:00 am, 11:00 am, 1:00 pm and 5: 00 pm during the 7:00 am to 7:00 pm (day shift). Resident #28 reported he was only administered one nebulizer treatment during the day shift on 3/9/24 and 3/10/24 and experienced chest pain on 3/9/24. [...]

Inspectors wroteBased on observations, staff interviews, and record reviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of wounds (Resident #399), hospice services (Resident #22), range of motion (Resident #11), and tube feeding (Resident #57). This deficient practice was identified for 4 of 18 sampled residents.

Inspectors wroteBased on record review, resident, responsible party (RP) and staff interviews, the facility failed to ensure group activities were planned for rehabilitation residents to meet the needs of the residents who expressed that it was important to them to attend group activities for 3 of 3 residents reviewed for activities (Resident #37, Resident #85 and Resident #88).

Inspectors wroteBased on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey of 9/29/22. This failure occurred for four repeat deficiencies cited for resident's rights, accuracy of assessments, maintenance of nutrition and hydration status, and infection prevention and control that was subsequently recited on the current recertification and complaint investigation survey of 3/26/24. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA Program.

Inspectors wroteBased on observations, staff interviews and record reviews the facility failed to implement their infection control policy when Nurse Aide (NA #4)) did not perform hand hygiene between residents during meal delivery and meal assistance and Nurse Aide (NA #12) failed to doff soiled gloves and perform hand hygiene before exiting Resident #57's room. This deficient practice was observed for 2 of 2 nursing assistants observed for hand hygiene and had the potential to result in the cross contamination of microorganisms between residents and environmental surfaces.

Inspectors wroteBased on observations, resident and staff interviews and record review, the facility failed to honor a resident's right to keep personal equipment in his room per his preference. This failure occurred for 1 of 2 sampled residents reviewed for personal property (Resident #36).

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure residents wheelchairs were in good repair for 2 of 2 residents reviewed for environmental concerns (Residents #54 and #94).

Inspectors wroteBased on record review, family interview, staff interviews and video observation, the facility failed to protect a resident's right to be free from misappropriation of resident property when a housekeeper staff member#1 (floor tech) used a resident's credit card and made multiple unauthorized purchases that included, the facility vending machine, grocery stores, gas stations, vape stores, shopping stores, restaurants and liquor stores. This occurred for 1 of 4 residents (Resident #98) reviewed for misappropriation of resident property.

Inspectors wroteBased on observations, record review, Nurse Practitioner, and staff interviews, the facility failed to recognize the use of an abdominal binder (a wide compression belt that encircles the abdomen) as a physical restraint for 1 of 1 resident (Resident #400) reviewed for physical restraints.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to develop an individualized, person-centered comprehensive care plan in the areas of wound care (Resident #399) and splints (Resident #11). This deficient practice was for 2 of 26 residents whose comprehensive care plans were reviewed.

Inspectors wroteBased on record review and staff interviews, the facility failed to revise the care plan for an intravenous (IV) medication (Resident #22). This was for 1 of 26 active resident care plans reviewed.

Inspectors wroteBased on record review, Nurse Practitioner, and staff interviews, the facility failed to transcribe the correct medication administration route for 1 of 3 residents reviewed for gastric feeding tube (Resident #400).

Inspectors wroteBased on observations, resident, staff and Nurse Practitioner interviews, the facility failed to accurately assess and failed to obtain wound care orders for skin condition of the right great toe and the right heel (Resident #399). The facility also failed to follow a physician order to remove staples from a surgical wound (Resident #93). The deficient practice was for 2 of 4 sampled residents for wound care (Resident #93 and Resident #399).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to apply bilateral knee splints according to therapy recommendations for 1 of 1 resident reviewed for limited range of motion (Resident #11).

Inspectors wroteBased on observations, interviews with the Registered Dietitian (RD), the Nurse Practitioner (NP) #1 and NP #2, staff, and record review, the facility failed to follow a recommendation from the RD to reweigh Resident #36 for further evaluation after an assessment of significant weight loss. Additionally, the facility failed to implement a plan from NP #2 in response to subtherapeutic total protein lab results for Resident #11. This failure occurred for 2 of 7 sampled residents reviewed for nutritional status.

Inspectors wrote3. Resident #198 was admitted to the facility on [DATE]. A physician order dated 2/27/24 specified Remedy nutrashield cream to buttock every shift and as needed for wound healing/prevention. Resident #198's physician orders did not indicate a cream ordered as needed to other areas of the skin. A review of the Minimum Data Set assessment dated [DATE] revealed Resident #198 was moderately cognitively impaired. An interview on 03/14/24 at 6:22 AM revealed Resident #198 was hurting and burning between her legs. Nurse #12 was informed 3/14/24 at 6:34 AM by this surveyor that Resident #198 was burning and hurting between her legs. Nurse #12 indicated he would go get cream for her. An observation with Nurse #12 of Resident #198 on 3/14/24 at 6:48 AM revealed Nurse #12 applied cream from a small tube to Resident #198's affected area. [...]

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to provide Resident #11 with a functional call light to request staff assistance for 3 of 3 days. This failure occurred for 1 of 2 sampled residents reviewed for a decline in activities of daily living.

Inspectors wroteBased on observations and staff interviews the facility failed to post daily nurse staffing in a prominent location that was readily accessible to residents on 5 of 5 days during the survey (03/11/2024, 03/12/2024, 03/13/2024, 03/14/2024, and 03/15/2024).

Inspectors wroteBased on observation, resident and staff interviews and record review, the facility failed to provide care in a manner to maintain the resident's dignity by not providing incontinence care when requested. This resulted in Resident #37 crying while waiting for incontinence care and she reported it made her feel worthless, horrible, bad and didn't deserve to be treated that way. This was evident for 1 of 6 residents who were reviewed for dignity and respect (Resident #37).

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to provide incontinence care when requested for 1 of 6 residents (Resident #37) reviewed for activities of daily living (ADL).

Inspectors wroteBased on observations, record review, staff interviews, and Registered Dietician (RD) interview, the facility failed to follow the RD's recommendation to reweigh a resident identified with significant weight loss to determine if the change in weight status was accurate for 1 of 5 residents reviewed for nutrition (Resident #26).

Inspectors wroteBased on observation, record review and interviews with facility staff, the facility failed to follow the manufacturer guidelines for cleaning and disinfection of a blood glucose meter that was stored in the medication cart prior to use for 1 of 1 resident observed (Resident #38). The blood glucose meter was stored in the medication cart and was not designated as an individual resident meter.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to accurately code a Minimum Data Set (MDS) assessment for 1 of 19 MDS assessments reviewed (Resident #64).