Inspection Reports for The Pavilion at Creekwood

The facility failed to provide appropriate wound care for Resident #1 by not applying a dressing to an infected wound, and failed to ensure pressure ulcers were properly managed for Residents #2, #3, and #4, including failure to offload pressure and use prescribed air boots, placing residents at risk for infection, delayed healing, and discomfort.

The complaint investigation was substantiated with findings that the facility failed to file and resolve a grievance for Resident #99 regarding refusal of incontinent care by CNA G, failed to complete a baseline care plan timely, had narcotic count discrepancies, and had a high medication error rate.

The facility failed to promptly resolve resident grievances, specifically failing to document and file a grievance for Resident #99 regarding incontinent care. The facility also failed to complete a baseline care plan within 48 hours for Resident #99. Pharmaceutical services were deficient, with narcotic count discrepancies for Resident #99 and a medication error rate of 24% for Residents #52 and #65, including crushing a medication that should not be crushed and late medication administration.

The complaint investigation revealed that the facility staff failed to communicate Resident #1's DNR status to EMS during an emergency on 08/21/2024, resulting in prolonged CPR despite the resident's wishes. The Immediate Jeopardy was identified on 08/26/2024 and removed on 08/27/2024 after corrective actions were implemented.

The facility failed to honor Resident #1's signed Out of Hospital DNR order when EMS was not informed of the DNR status, resulting in CPR being initiated for approximately 43 minutes. An Immediate Jeopardy was identified but later removed after the facility implemented a Plan of Removal including staff re-education and procedural changes to ensure proper communication of code status to EMS.

The complaint investigation found that the facility failed to administer prescribed medications to residents #1 through #5 on or shortly after admission, including antipsychotic Clozapine for Resident #1, multiple medications for Residents #2, #3, and #4, and Flonase allergy spray for Resident #5. Resident #4 was also prescribed an antipsychotic without adequate clinical indication. The investigation included interviews with staff and review of medical records, medication administration records, and physician orders.

The facility failed to provide prescribed medications to five residents upon admission, including delays in administering antipsychotic and other medications, resulting in potential harm. Additionally, the facility failed to ensure that one resident's drug regimen was free from unnecessary drugs, prescribing an antipsychotic without adequate indication.

The facility failed to ensure residents' rights to reasonable accommodation by not providing timely assistance to Resident #15 after she activated her call light, resulting in unmet needs. Additionally, the facility failed to properly store food in the kitchen refrigerator and freezer, risking food-borne illness.

The complaint was substantiated. Family members reported multiple calls to remind staff to place the CPAP on Resident #1 at night and during naps. The facility acknowledged the issue and conducted in-service training for nursing staff. Observations confirmed the resident was not always wearing the CPAP during naps despite orders.

The facility failed to ensure that Resident #1 received respiratory care consistent with professional standards and the care plan, specifically failing to apply the CPAP machine as ordered during sleep and naps. Observations, interviews, and record reviews confirmed inconsistent CPAP use, late documentation, and staff awareness of the issue despite in-service training.

The facility failed to maintain sanitary conditions in four clean linen closets (100, 200, 300, 400 Halls), with observations of gowns, gloves, trash, pillows, and other items improperly stored on the floor, posing a risk of cross-contamination and infection to residents. Staff interviews confirmed responsibility issues and lack of recent cleaning or in-servicing.

The facility failed to maintain sanitary conditions in four clean linen closets, with various non-linen items and trash observed on the floors, risking cross-contamination. Additionally, the facility failed to ensure a working call light system for one resident, which could place residents at risk of not receiving timely assistance.

The facility failed to ensure that all drugs and biologicals were stored in locked compartments for one of five residents reviewed. Resident #1 had nasal spray and antacid pills stored unsecured at the bedside table, posing a risk of unsafe medication consumption. Interviews revealed lack of assessment and physician orders for self-administration, and staff were unaware of medications being left in the resident's room.

The complaint investigation found that the facility failed to notify Resident #2's responsible party about new wounds discovered on 02/13/23 and failed to conduct and document weekly skin assessments as ordered. The facility also failed to provide wound care treatments as ordered for Residents #5 and #7 on 02/15/23. Interviews with staff confirmed lack of notification and treatment. The responsible party for Resident #2 confirmed no notification was received.

The facility failed to notify Resident #2's responsible party about new wounds and failed to conduct timely and documented weekly skin assessments. Additionally, the facility failed to provide wound care treatments as ordered for Residents #5 and #7, placing residents at risk of harm due to untreated wounds and lack of proper notification.

The facility was found deficient in multiple areas including failure to accommodate resident needs such as accessible call lights, incomplete and unimplemented care plans for residents, lack of annual performance reviews for nurse aides, and inadequate infection prevention and control practices including improper PPE use, equipment sanitization, and sharps container management.