Pavilion on Main Street, the

Inspectors wroteBased on interview and record review the facility failed to ensure resident safety during transportation to an outside appointment for 1 of 3 residents (R1) reviewed for safety in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a bed rail was maintained in a safe manner for 1 of 3 residents (R1) reviewed for resident injury in the sample of 9. This failure resulted in R1 receiving an injury to her right lateral leg, being sent to a local hospital where she received stitches for her injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's medications were available and administered as ordered for 1 of 3 residents (R4) reviewed for medications in the sample of 10.

Inspectors wroteBased on observation, interview and record review the facility failed to safely handle a resident to prevent multiple skin tears. This failure resulted in R92 being transferred to the emergency room (ER) after a transfer which contributed to R92 sustaining a large skin tear requiring 11 stitches/sutures. This applies to 1 of 23 residents (R92) reviewed for safety in the sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure dietary recommendations were implemented for residents with a history of significant weight loss. This failure resulted in R43 and R93 not receiving their therapeutic diets as ordered for their severe weight loss. This applies to 2 of 9 residents (R43, R93) reviewed for weight loss in the sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to prepare pureed foods in a manner to maintain its nutritive value. The facility failed to serve mechanical soft foods to residents that required a mechanical soft diet. The facility failed to serve foods according to their daily menu. These failures apply to all 97 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure kitchen utensils were stored in a sanitary manner. The facility failed to ensure food was prepared in a manner to prevent cross contamination. The facility failed to ensure kitchen staff covered facial hair to prevent cross contamination. The facility failed to maintain the kitchen in a sanitary manner. These failures have the potential to affect all 97 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents receiving pureed diets were served appetizing and flavorful meals for 4 of 4 residents (R73, R43, R93 & R6) reviewed for palatability in the sample of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a homelike environment. This applies to 2 of 23 (R8, R85) reviewed for homelike environment in the sample of 23.

Inspectors wroteBased on interview and record review the facility failed to ensure baths were provided as scheduled for 2 of 23 residents (R56 & R91) reviewed for Activities of Daily Living (ADL's) in the sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician's orders for a dermatology consult for a resident with a persistent body rash, ongoing since July 2025. This applies to 1 of 23 residents reviewed for quality of care in a sample of 23.

Inspectors wroteBased on observation interview and record review the facility failed to administer medication as ordered. There were 30 opportunities with 2 errors resulting in a 6.67% error rate. This applies to 2 of 4 residents (R51, R35) reviewed for medication administration in a sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the glucose monitoring machine was cleaned after each resident use. This applies to 2 of 23 residents (R21 and R23) reviewed for infection control in the sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to immediately isolate residents with a suspected infectious rash. The facility failed to ensure staff did not expose residents to a suspected infectious rash. The facility failed to ensure residents on isolation remained in their rooms to prevent the possible spread of infection. The facility failed to clean and disinfect resident rooms and linen in a manner to prevent the possible re-exposure of a skin infection. These failures have the potential to affect all 94 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to employ an Infection Preventionist that had successfully tested and completed infection preventionist training and education. This failure has the potential to affect all 94 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wore beard coverings when serving food. This applies to 4 of 4 residents (R52, R70, R43, R80) reviewed for food sanitation in the sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor a resident during medication administration. This applies to 1 of 4 residents (R79) reviewed for pharmacy services in the sample of 19.

Inspectors wroteBased on interview and record review the facility failed to supply a bed hold notice to a resident representative at the time of transfer for 1 of 1 resident (R1) reviewed for resident rights in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pain control for a resident with fractured ribs for 1 of 1 resident (R289) reviewed for pain. This failure resulted in R289 experiencing difficulty sleeping, difficulty participating in therapy and uncontrolled pain.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure sufficient staffing for all 86 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen tanks were stored in a secure manner (R44, R78, R33) and failed to transfer a resident in a safe manner (R8) for four of four residents reviewed for falls in the sample of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide timely incontinence care for a dependent resident for 1 of 1 resident (R38) reviewed for incontinence care in the sample of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure physician ordered wound dressings were completed as ordered for 2 of 2 residents (R46, R47) reviewed for non-pressure wounds in the sample of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure reduction interventions were in place and failed to identify and report skin changes for a resident at a high risk for pressure for one of nine residents (R78) reviewed for pressure in the sample of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure indwelling catheter care was performed in a manner to prevent cross contamination (R25) and failed to ensure an indwelling catheter was changed as ordered (R6) for two of two residents reviewed for catheters in the sample of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to change a PICC (Peripheral Inserted Central Catheter) line dressing for 1 of 1 residents (R6) reviewed for intravenous catheters in the sample of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a prescribed medication was available for administration for 1 of 1 resident (R289) reviewed for pharmacy services.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy by not ensuring medications were stored properly for three of three residents (R288, R84, R20) reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure PPE (personal protective equipment) was used in a manner to prevent cross contamination and failed to clean equipment after use in a contact isolation room (R33) and failed to cleanse a resident in a manner to prevent cross contamination (R13) for two of two residents reviewed for infection control in the sample of 21.